LIRRARY OF CONGRESS. 



©Iptp dup^rigfc ^0, 

Shelf ...L^.^V 

UNITED STATES >F AMERICA. 



A TEXT-BOOK 



OF THE 



PRINCIPLES AND PRACTICE 



OF 



MEDICINE 



FOR THE 



USE OF MEDICAL STUDENTS AND PRACTITIONERS. 



H& 



BY 



HENRY M. LYMAN, A.M., M.D., 

PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN RUSH MEDICAL COLLEGE, CHICAGO. 



WITH ONE HUNDRED AND SEVENTY ILLUSTRATIONS. 




3f V 



I 



PHILADELPHIA: 
LEA BROTHERS & CO. 

1892. 



T=> 






Entered according to the Act of Congress, in the year 1892, by 

LEA BROTHERS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



nOENAN, PB1NTK1I, 
PHILADELPHIA. 



TO 



STEPHEN SMITH, M.D., 



PHYSICIAN, SURGEON, AUTHOR, AND TEACHER, 



THIS VOLUME 



DEDICATED 



GRATEFUL PUPIL 



PREFACE. 



In this volume I have endeavored to present, in addition to the fruits 
of my own observation and experience, the substance of the latest editions 
of the works of Ziegler, Hallopeau, Eichhorst, Cornil, and Babes, and of 
the collaborators of the Traite de Medecine. 

In order to secure the greatest possible brevity, matters of an historical 
and controversial nature have been omitted, and every effort has been 
made to exclude whatever is not absolutely essential for the information 
of the student. Numerous interesting topics have accordingly received 
but brief notice. It has seemed best to aim at the construction of a 
definite framework which the future physician can clothe with the results 
of subsequent reading and observation. 

In the arrangement of topics I have ventured upon a departure from 
the time-honored order of sequence. Having acquired a knowledge of 
the diseases that involve the external surface of the body, of which so 
many are of a parasitic nature, it seems best to begin the study of 
internal medicine by continuing the investigation of parasitic diseases. 
This leads to a consideration of the infective diseases and the disorders 
of the alimentary canal and respiratory organs, through which so many 
contagia find entrance into the body. Diseases of the blood and of the 
organs of circulation lead naturally to the inflammations and degener- 
ations ; and disorders of nutrition and of the nervous tissues complete 
the field of observation. 

If the sections that are devoted to medicines and their administration 
seem brief, they have been so arranged with the purpose of presenting 
the best methods of treatment and of preventing the confusion which 
would be caused by listing a multitude of remedies, among which it is 
difficult to decide in favor of the best. The medicinal agents and the 
doses that are set forth are usually those which are the most generally 
applicable in hospital practice and in treating the majority of patients. 



CONTENTS. 

PART I. 

PRELIMINARY CONSIDERATIONS. 



PA G E 



CHAPTER I. 

Introductory 17 

CHAPTER II. 

Growth and Development . . . . • . • • . .20 

CHAPTER III. 

Eegressive Disturbances of Nutrition 20 

CHAPTER IV. 

Progressive Disturbances of Nutrition 27 

CHAPTER V. 

Tumors — Fibroma, Myxoma, Endothelioma, Cholesteatoma, Glioma, Lipoma, 
Sarcoma, Enchondroma, Osteoma, Angioma, Lymphangioma, Lympho- 
ma, Myoma, Myo-sarcoma, Epithelioma, Cylindrical Epithelioma, Car- 
cinoma, Cylindroma, Neuroma, Teratoma ..... 29-44 

CHAPTER VI. 

Disorders Induced by Disturbances of Circulation —Dropsy .... 44 

CHAPTER VII. 

Contagion, and Infective Diseases . ........ 48 

CHAPTER VIII. 

Inflammation • 61 

CHAPTER IX. 

Fever 68 



VI il CONTENTS. 

P AET II. 

PARASITIC AND INFECTIVE DISEASES. 

DISEASES CAUSED BY ANIMAL PARASITES. 

CHAPTER I. 



PAGE 



Intestinal Worms — Nematoid Worms— Lumbricoid Worms, ( )xyuris Vermicu- 
laris, Filaria, Filaria Sanguinis Hominis, Trichina, Trichocephalus Dis- 
par, Anchylostomum Duodenale, Anguillula Intestinalis and Anguillula 
Stercoralis, Strongylus Gigas. Cestoid or Tape Worms — Taenia Solium, 
Taenia Mediocanellata, Taenia Echinococcus, Bothriocephalic Latus. 
Trematoid or Fluke Worms — Distoma Hepaticum, Distoma Haemato- 
bium or Bilharzia 77-92 

CHAPTER II. 

Protozoa 92 

CHAPTER III. 

Malarial Fever — Remittent Fever, Pernicious Fever, Malarial Cachexia . 93-104 

CHAPTER IV. 

Dysentery 105 

DISEASES CAUSED BY VEGETABLE PARASITES. 

CHAPTER V. 

Actinomycosis . . . . . . . . . . . . .111 

CHAPTER VI. 

Malignant Pustule 112 

CHAPTER VII. 

Typhoid Fever 115 

CHAPTER VIII. 
Influenza — Grippe ............ 136 

CHAPTER IX. 

Diphtheria 140 

CHAPTER X. 

Tetanus 151 



CONTENTS. IX 

CHAPTER XI. 

PAGE 

Tuberculosis — Scrofula, Pulmonary Consumption, Laryngeal Tuberculosis, 
Intestinal Tuberculosis, Tuberculosis of the Kidneys and Urinary Organs, 
Miliary Tuberculosis, Tubercular Meningitis, Tubercular Pleurisy, Tuber- 
cular Pericarditis, Tubercular Peritonitis ..... 154-191 

CHAPTER XII. 

Glanders— Farcy 192 

CHAPTER XIII. 

Syphilis — Syphilis of the Nose, Laryngeal Syphilis, Tracheal and Bronchial 
Syphilis, Pulmonary Syphilis, Syphilis of the Alimentary Canal, Hepatic 
Syphilis, Syphilis of the Spleen, Kenal Syphilis, Syphilis of the Sexual 
Organs, Syphilitic Diseases of the Vascular Organs, Cerebral Syphilis, 
Syphilis of the Spinal Cord, Syphilis of the Peripheral Nerves, Heredi- 
tary Syphilis 197-216 

CHAPTER XIV. 

Epidemic Cerebro-spinal Meningitis . . . . . . . . .216 

CHAPTER XV. 

Erysipelas 220 

CHAPTER XVI. 

Mumps— Parotitis 226 

CHAPTER XVII. 

Secondary Parotitis 227 

CHAPTER XVIII. 

Kotheln — German Measles — Eubeola 228 

CHAPTER XIX. 

Measles 230 

CHAPTER XX. 

Scarlet Fever — Scarlatina ........... 236 

CHAPTER XXI. 

Whooping-cough 244 

CHAPTER XXII. 

Break-bone Fever — Dengue 248 

CHAPTER XXIII. 

Kelapsing Fever 251 



X CONTEXTS. 

CHAPTER XXIV. 
Cholera :!">''. 

CHAPTER XXV. 

Typhus Fever I 

CHAPTEK XXVI. 

The Plague _ - 

CHAPTER XXVII. 

Yellow Fever 271 

CHAPTER XXVIII. 

Chickenpox 276 

CHAPTER XXIX. 

Smallpox . . . . . . . . . . . . . J7^ 

CHAPTER XXX. 

Hydrophobia .2 

CHAPTER XXXI. 

On the Management of Infective Pi- 



PAET II I. 
DI>EA>E> OF THE ALIMENTARY CANAL. 

CHAPTER I. 

> of the Mouth — Catarrhal Inflammation of the Mouth. Ulceration 
of the Mouth. Stomatitis Aphthosa, Leueoplacia Oris. Thrush. < >ral 
Parasites 307-313 

CHAPTER II. 

the Salivary Gland — -Salivation, Fibrinous Inflammation of the 
Salivary Ducts 313-315 

(IIAPTEK III. 

the Fauces and Pharynx— Acute Catarrhal Inflammation of the 
Fauces and Pharynx, Chronic < atarrh of tin- Fame- and Pharynx 315-319 



CONTENTS. XI 

CHAPTER IV. 

PAGE 

Diseases of the (Esophagus — Constriction of the (Esophagus, Cancer of the 
(Esophagus, Dilatation of the (Esophagus, Sacculation of the (Esophagus, 
Catarrhal Inflammation of the (Esophagus, Phlegmonous Inflammation 
of the (Esophagus 319-326 

CHAPTER V. 

Diseases of the Stomach — Gastric Hemorrhage, Acute Gastric Catarrh, Chronic 
Gastric Catarrh, Purulent Gastritis, Toxic Inflammation of the Stomach, 
Gastric Ulcer, Cancer of the Stomach, Dilatation of the Stomach . 327-347 

CHAPTER VI. 

Functional Diseases of the Stomach — Motor Neuroses, Nervous Vomiting, 
Eructation, Kumination, Sensory Neuroses of the Stomach, Gastralgia, 
Nervous Dyspepsia 347-352 

CHAPTER VII. 

Diseases of the Intestines — Acute Catarrhal Inflammation of the Bowels, 
Acute Infantile Gastro- enteritis, Chronic Catarrhal Inflammation of the 
Bowels, Inflammation of the Ccecum and Vermiform Appendix, Intesti- 
nal Cancer, Intussusception, Intestinal Constriction and Occlusion, Haemor- 
rhoids, Intestinal Hemorrhage, Mel sen a Neonatorum, Colic . . 352-373 



PAET IV. 

DISEASES OF THE LIVER, PANCREAS, PERITONEUM, 
AND SPLEEN. 

CHAPTER I. 

Diseases of the Liver — Constriction and Occlusion of the Biliary Passages, 
Catarrhal Jaundice, Suppuration of the Gall-bladder, Dropsy of the Gall- 
bladder, Cancer of the Biliary Passages, Biliary Calculi — Gall-stones 375-385 

CHAPTER II. 

Diseases of the Hepatic Parenchyma, Venous Congestion of the Liver, Acute 
Congestion of the Liver, Perihepatitis, Abscess of the Liver, Cirrhosis of 
the Liver, Acute Yellow Atrophy of the Liver, Fatty Liver, Amyloid 
Liver, Cancer of the Liver 385-402 

CHAPTER III. 

Diseases of the Hepatic Bloodvessels, Portal Thrombosis, Suppuration of the 

Portal Vein 402-404 



Xll CONTENTS. 

PAGE 

CHAPTER IV. 
I tiseases of the Pancreas 404 

CHAPTER V. 

Diseases of the Peritoneum — Inflammation of the Peritoneum, Peritoneal 

Dropsy, Peritoneal Cancer 404-413 

CHAPTER VI. 

Diseases of the Spleen — Acute Enlargement of the Spleen, Chronic Enlarge- 
ment of the Spleen, Embolic Infarction of the Spleen, Perisplenitis, In- 
flammation of the Spleen, Amyloid Degeneration of the Spleen, Cancer 
of the Spleen, Rupture of the Spleen, Wandering Spleen . . 413-419 



PART Y. 

DISEASES OF THE ORGANS OF RESPIRATION. 

DISEASES OF THE RESPIRATORY APPARATUS. 

CHAPTER I. 

Diseases of the Nasal Passages, Nasal Catarrh — Coryza, Hay Fever . 421-42") 

CHAPTER II. 

Diseases of the Larynx — Catarrhal Inflammation of the Larynx. (Edema of 

the Glottis, Perichondria! Inflammation of the Larynx . . . 42o-432 

CHAPTER III. 

Laryngeal Neurosis — Paralysis of the Laryngeal Muscles. Spasm of the 

Glottis * 433-437 

CHAPTER IV. 

Diseases of the Trachea and Bronchi — Catarrhal Inflammation of the Bronchi, 
Fibrinous Bronchitis, Bronchial Dilatation, Bronchial Constriction, Bron- 
chial Asthma, Inflammation of the Tracheo-bronchial Lymph-glands . 438-467 

CHAPTER V. 

Diseases -of the Lungs — Pulmonary Hemorrhage, Alveolar Emphysema, Inter- 
lobular Emphysema, Pulmonary Collapse, Pulmonary Hypostasis, (Edema 
of the Lungs, Catarrhal Inflammation of the Lungs, Fibrinous Pneu- 
monia, Interstitial Pneumonia, Pulmonary Abscess, Gangrene of the 
Longs, Pulmonary Cancer ......... 457-490 



CONTENTS. XII 



CHAPTER VI. 



Diseases of the Pleura — Pleurisy, Pneumothorax, Hydrothorax, Hemothorax 

and Chylothorax, Cancer of the Pleura 491-514 

CHAPTER VII. 

Diseases of the Mediastinum — Mediastinal Inflammation, Mediastinal Hemor- 
rhage, Mediastinal Tumors 514-516 

CHAPTER VIII. 

Diseases of the Thymus Gland 517 



PART VI. 

DISEASES OF THE ORGANS OF CIRCULATION. 

DISEASES OF THE CIRCULATORY APPARATUS. 

CHAPTER I. 

Endocardial Diseases — Ulcerative Endocarditis, Verrucose Endocarditis, 
Chronic Endocarditis, Diseases of the Cardiac Valves, Aortic Insufficiency, 
Aortic Stenosis, Mitral Insufficiency, Mitral Stenosis, Insufficiency of the 
Pulmonary Valve, Stenosis of the Pulmonary Valve, Insufficiency of the 
Tricuspid Valve, Stenosis of the Triscuspid Valve, Stenosis of the Heart, 
Associated Defects of the Cardiac Valves, Congenital Valvular Lesions of 
the Heart, Congenital Cyanosis, Cardiac Thrombosis . . . 519-546 

CHAPTER II. 

Diseases of the Muscular Substance of the Heart — Dilatation of the Heart, 
Hypertrophy of the Heart, Atrophy of the Heart, Fatty Heart, Acute 
Inflammation of the Heart, Chronic Inflammation of the Heart, Rupture 
of the Heart, Tumors of the Heart, Parasites, Misplacement of the Heart, 
Diseases of the Coronary Arteries ....... 547-562 

CHAPTER III. 

Neuroses of the Heart — Paroxysmal Tachycardia — Palpitation of the 
Heart, Paroxysmal Bradycardia, Intermittent Heart, Cardiac Neuralgia, 
Angina Pectoris, Exophthalmic Goitre 562-571 

CHAPTER IV. 

Diseases of the Pericardium — Pericarditis, Pericardial Adhesion, Hydropneu- 
monopericardium, Dropsy of the Pericardium, Hremopericardium, Chylo- 
pericardium ... . .....•• 572-583 



XIV CONTENTS. 

CHAPTER V. 

PAGE 

I>i-»;i>es of the Aorta — Acute Inflammation of the Aorta, Chronic Inflamma- 
tion of the Aorta, Aneurism of the Aorta, Constriction and Occlusion of 
the Isthmus of the Aorta, Congenital Narrowness of the Entire Aorta, 
Kupture of the Aorta, Embolism of the Aorta, Thrombosis of the 
Aorta 58 



P A RT VII. 

DISEASES OF THE BLOOD. 

CHAPTER I. 

Diseases of the Blood — Leukaemia, Pseudo-leukemia, Progressive Pernicious 
Anaemia, Chlorosis, Melanaemia, Purpura, Purpura Simplex, Purpura 
Hemorrhagica, Scurvy, Scorbutus, Paroxysmal Hemoglobinuria, Hemo- 
philia 595-619 



PART VIII. 
DISEASES OF NUTRITION. 

CHAPTER I. 

Pickets )>21 

CHAPTER II. 

Osteomalacia ... . ......... 628 

CHAPTER III. 
Obesity ... 639 

CHAPTER IV. 
Saccharine Diabetes . 640 

CHAPTER V. 

Polyuria .... (r>3 

CHAPTER VI. 
Goal 657 

CHAPTER VIE 

Nodular Rheumatism ........... 



CONTENTS. XV 

PAGE 

CHAPTER VIII. 

Acute Rheumatism, Chronic Rheumatism, Muscular Rheumatism . . G72-681 

CHAPTER IX. 

Alcoholism . . . 681 



CHAPTER X. 



Morphinism 



686 



CHAPTER XI. 

Cocai'nism . . . ......... 688 

CHAPTER XII. 

Chronic Nicotinism . . 688 



PAKT IX. 

DISEASES OF THE KIDNEYS AND GENITOURINARY 

ORGANS. 

CHAPTER I. 

General Renal Diseases — Albuminuria, Hematuria, Hemoglobinuria . 691-698 

CHAPTER II. 

Diseases of the Renal Parenchyma — Ischemia of the Kidneys, Venous Hyper- 
emia of the Kidneys, Diffuse Inflammation of the Kidneys, Acute Paren- 
chymatous Inflammation of the Kidneys, Chronic Parenchymatous Inflam- 
mation of the Kidneys, Chronic Interstitial Nephritis, Uraemia, Renal 
Abscess, Amyloid Kidney, Fatty Kidney, Embolic Infarction of the Kid- 
neys, Cancer of the Kidney, Renal Cysts, Movable Kidney, Horse-shoe 
Kidney, Para-nephritis, Diseases of the Suprarenal Capsules, Addison's 
Disease -. 698-730 

CHAPTER III. 

Diseases of the Renal Pelvis and of the Ureter — Hydronephrosis, Pyelitis, 

Renal Calculi 730-739 

CHAPTER IV. 

Diseases of the Bladder — Chronic Diseases of the Bladder, Catarrh of the 
Bladder, Cancer of the Bladder, Functional Diseases of the Bladder, 
Enuresis Nocturna, Hyperesthesia and Spasm of the Bladder, Paralysis 
of the Bladder 739-747 



XVI CONTEXTS. 

CHAPTER V. 

PAGE 

Diseases of the Male Organs of Generation — Impotence, Aspermatism, Azoo- 
spermia, Spermatorrhoea, Prostatorrho-a ...... 747-751 



PART X. 

DISEASES OF THE XERVOUS SYSTEM. 

CHAPTER I. 

Diseases of the Peripheral Nerves — Diseases of the Motor Nerves, Paralysis 
of the Motor Nerves, Facial Paralysis, Paralysis of the Motor Portion of 
the Trigeminal Nerve, Paralysis of the Spinal Accessory Nerve, Paralysis 
of the Hypoglossal Nerve, Paralysis of the Radial Nerve, Paralysis of the 
Median Nerve, Paralysis of the Ulnar Nerve, Paralysis of the Musculo- 
cutaneous Nerve, Paralysis of the Axillary Nerve, Associated Paralysis 
of the Upper Extremity. Paralysis of the Serratus Muscle, Peripheral 
Paralysis of the Nerves of the Lower Extremities .... 753-769 

CHAPTER II. 

Spasm of the Motor Nerves— Spasm of the Facial Nerve, Spasm of the Mus- 
cles of Mastication, Hypoglossal Spasm, Accessory Nerve Spasm. Spasm 
of the Muscles in the Neck, Shoulder, and Arm ; Spasm of the Splenitis 
Capitis Muscle, Spasm of the Rhomboid Muscle, Spasm of the Levator 
Anguli Scapula? Muscle, Spasm of the Diaphragm, Tonic Spasm of the 
Diaphragm, Spasm of the Muscles in the Lower Extremities. . . 769-774 

CHAPTER III. 

Diseases of the Sensory Nerves — Neuralgia, Trigeminal Neuralgia, Occipital 
Neuralgia, Phrenic Neuralgia, Cervico-Brachial Neuralgia, Intercostal 
Neuralgia, Mammary Neuralgia, Lumbo- Abdominal Neuraluia. Crural 
Neuralgia, Obturator Neuralgia, Sciatica. Neuralgia Ischiadica, Spermatic 
Neuralgia, Coccygodynia. Neuralgia of the Joints .... 774-782 

CHAPTER IV. 
Amesthesia — Anaesthesia of the Trigeminal Nerve .... 

CHAPTER V. 

Diseases of the Nerves of Special Sense — Olfactory Hyperesthesia, Olfactory 
Anaesthesia, Olfactory Paresthesia. Gustatory Hyperesthesia, Gustatory 
Anaesthesia, Gustatory Paresthesia 781 

CHAPTER VI. 

Organic Diseases <>!* the Peripheral Nerve — Inflammation of the Nerves, 
Neuritis, Multiple Neuritis, Toxic Paralysis, Mercurial Paralysis, Arsenical 
Paralysis, Phosphorus Paralysis, Alcoholic Paralysis .... 787 



CONTENTS. XVll 

PART XI. 

DISEASES OF THE SPINAL CORD AND MEMBRANES. 

PAGE 

CHAPTER I. 

Preliminary Considerations 793 

CHAPTER II. 

Diseases of the Spinal Meninges — External Inflammation of the Spinal Dura- 
mater, Internal Inflammation of the Spinal Dura-mater, Acute Spinal 
Meningitis, Chronic Spinal Meningitis, Spinal Meningeal Hemorrhage, 
Tumors of the Spinal Meninges 798-804 

CHAPTER III. 

Functional Diseases of the Spinal Cord — Spinal Irritation, Acute Ascending 
Spinal Paralysis, Keflex Paralysis, Psychic Spinal Paralysis, Writer's 
Cramp, Tetany, Congenital Myotonia, Paramyoclonus Multiplex . 804-810 

CHAPTER IV. 

Organic Unsystematized Diseases of the Spinal Cord — Spinal Anaemia, Spinal 
Hyperemia, Passive Hyperemia, Spinal Hemorrhage, Acute Inflammation 
of the Spinal Cord, Chronic Inflammation of the Spinal Cord, Embolic 
and Thrombotic Softening of the Spinal Cord, Multiple-Cerebro-Spinal 
Sclerosis, Tumors of the Spinal Cord, Cavities in the Spinal Cord . 810-821 

CHAPTER Y. 

Traumatic Diseases of the Spinal Cord— Concussion of the Spinal Cord, Com- 
pression of the Spinal Cord, Injuries of the Spinal Cord, Spinal Hemi- 
plegia 821-825 

CHAPTER VI. 

Systematized Diseases of the Spinal Cord — Progressive Locomotor Ataxia, 
Spastic Spinal Paralysis, Acute Infantile Paralysis, Acute, Sub-acute, 
and Chronic Spinal Paralysis of Adults, Spinal Progressive Muscular 
Atrophy 826-838 

CHAPTER VII. 

Combined System-Diseases of the Spinal Cord — Hereditary Ataxia, Secondary 

Degeneration of the Spinal Cord, Amyotrophic Lateral Sclerosis . 838-840 

CHAPTER VIII. 

Diseases of the Medulla Oblongata — Progressive Bulbar Paralysis, Progressive 
Nuclear Ophthalmoplegia, Bulbar Hemorrhage, Embolism and Throm- 
bosis of the Bulbar Arteries, Acute Inflammation of the Medulla 
Oblongata, Bulbar Tumors, Injuries and Compression of the Medulla 
Oblongata 840-846 



XV111 CONTENTS. 



PAKT XII. 

DISEASES OF THE SYMPATHETIC NERVES AND OF 
THE MUSCLES. 

PACE 

CHAPTER I. 

Diseases of the Sympathetic Nerves — Irritation of the Cervical Sympathetic 
Nerve, Paralytic Conditions of the Cervical Sympathetic Nerve, Hemi- 
crania, Progressive Facial Hemiatrophy, Acromegaly, Myxoedema, Ery- 
thromelagia, Intermittent Articular Dropsy, Intermittent Angioneurotic 
(Edema, Symmetrical Gangrene 847-853 

CHAPTER II. 

Diseases of the Muscles — Pseudo-Muscular Hypertrophy, Juvenile Progres- 
sive Muscular Atrophy, Progressive Muscular Ossification, Acute Multi- 
ple Muscular Inflammation 853-857 



PAKT XIII. 
DISEASES OF THE BRAIN AND CEREBRAL MEMBRANES. 

CHAPTER I. 

Diseases of the Cerebral Membranes— Thrombosis and Inflammation of the 
Cerebral Sinuses, Hemorrhagic Pachymeningitis, Meningeal Hemor- 
rhage 859-S(i2 

CHAPTER II. 

Diseases of the Brain —Preliminary Considerations, Local Symptoms of Dis- 
eases of the Cerebral Cortex, Local Symptoms in Diseases of the Centrum 
Ovale, Local Symptoms Produced by Diseases of the Internal Capsule, 
Local Symptoms of Disease in the Basal Cerebral Ganglia, Local Symp- 
toms in Disease of the Crura Cerebri, Local Symptoms in Disease of the 
Pons Varolii, Diseases of the Thalamus Opticus, Diseases of the External 
Capsule and Claustrum, Diseases of the Corpora Quadrigemina, Diseases 
of the Cerebellum, Diseases of the Crura Cerebelli, Local Symptoms in 
Diseases at the Base of the Brain, Aphasia, Agraphia, Alexia, Amimia, 
Apraxia, Asymbolia 862 v 7 [ 



CONTENTS. XIX 

CHAPTER III. 

Diseases of the Cerebrum — Cerebral Anaemia, Cerebral Hyperemia, Sun- 
stroke, Thermic Fever, Cerebral (Edema, Cerebral Hemorrhage, Em- 
bolism and Thrombosis of the Cerebral Arteries, Cerebral Inflammation, 
Cerebral Tumors, Cerebral Aneurism, Hydrocephalus, Cerebral Hyper- 
trophy, Cerebral Atrophy, Diffuse Cerebral Sclerosis, Acute Cerebral 
Infantile Paralysis 874-895 

CHAPTER IV. 

Functional Diseases of the Brain, Epilepsy, Eclampsia, St. Vitus's Dance, 
Prse- and Post-Athetosis, Shaking Palsy, Tremor, Vertigo, Catalepsy, 
Hysteria, Neurasthenia . . . 895-914 



PART I. 
PRELIMINARY CONSIDERATIONS. 



CHAPTER I. 

ORGANIZATION OF THE BODY. 

Every living creature that inhabits the earth is provided with an 
organized body, of which the simplest form is a mere speck of appa- 
rently undifferentiated protoplasm constituting a spore or cell ; but 
for the higher orders of existence the body consists of members and of 
organs that have been formed by the orderly arrangement and connec- 
tion of simpler organisms, called elementary parts or cells. These con- 
sist chiefly of protoplasm that has been formed by the union of inorganic 
molecules that have been united by chemical attraction, and are retained 
in a state of moving equilibrium by the molecular and physical forces 
that operate upon all forms of matter. In this respect a vegetable or 
an animal organism possesses much that is common with the mineral 
constituents of the globe ; but it requires very little observation to dis- 
cover certain notable differences between the formation and growth of 
a crystal, which may be considered as the type of mineral structures, 
and the growth and- development of a plant or of a frog. The crystal 
enlarges by accretion. Chemical, molecular, and physical forces seem to 
be sufficient for its formation, but for the development and growth of a 
plant or of an animal, something more is required. Such structures con- 
sist of numerous parts, which, in their turn, are composed of individual 
cells, and these cells possess the power of division and multiplication. 
They increase, not by accretion, but by assimilation of matter which 
enters the inmost substance of the mass, and there becomes incorporated 
with it through the agency of chemical attraction. This process, how- 
ever, does not go on indefinitely, but is conducted in such a way as to 
result in the evolution, for each species of plant or animal, of a different 
structure, possessing certain average characteristics of form, size, and 
function. Apparently something more than ordinary chemical attrac- 
tion is concerned in this process. 

In the present state of our knowledge it is, therefore, convenient to 
assume the existence of special organizing or vital forces, that coordi- 
nate in living bodies the chemical, physical, and molecular attractions 
that operate between all forms of matter. This assumption may be 

2 



18 PRELIMINARY CONSIDERATIONS. 

employed as a convenient working hypothesis ; but the student must 
not consider this an explanation that throws any light upon the nature 
of such coordinating forces. It is probable that, like all other material 
forces, they are to be looked upon as local and temporal manifesta- 
tions of the Infinite and Imminent Power by which the Universe is 
evolved. 

Organic structures that have been thus formed are said to be alive 
so long as the organic forces that are active among the atoms and mole- 
cules are coordinated and dominated by the vital force that sustains 
their organization ; but if this force be overcome by the operation of 
antagonistic forces, it ceases to act, and life is merged in death. The 
ordinary course of chemical exchange is resumed among the molecules 
of the now dead body ; disintegration (the reverse of organization) 
rapidly resolves the structure into its original inorganic components, 
and the organism ceases to exist. But sometimes it happens that the 
antagonistic forces of Nature do not operate with violence sufficient to 
inhibit the vital forces in a given body. The ordinary forces of Nature, 
light, heat, electricity, gravitation, etc., often encounter the living body 
with violence sufficient to cause its death ; but under other conditions 
their intensity may be so far modified that instead of antagonizing 
vital force, they stand in favorable concurrence with its coordinative 
activity, and thus aid in the evolution of the phenomena of life. The 
heat of the sun that in midsummer burns up the crops, is in spring 
and in autumn most favorable to their growth. The electrical current 
that paralyzes a nerve or a muscle, may be so moderated that, instead 
of arresting, it shall greatly invigorate the functions of such organs. 

It appears, therefore, that every living body, whether plant or animal, 
is formed under the influence of vital forces that appropriate and 
organize non-living matter in the presence of other forces that may favor 
or may oppose this process. Between these poles of favor and oppo- 
sition lie many zones of more or less perfect organization. Observation 
shows that not every living body presents an established type of uniform 
structure and function. There may be imperfect development of cer- 
tain organs, as in hermaphrodites ; there may be unsymmetrical growth, 
as when one limb is smaller than the other ; or the body, though well 
formed, may differ in size and strength from the usual dimensions of 
its kind ; again, a body that was perfectly organized may be invaded 
by parasites that seek to appropriate for their own use matter that is 
needed to maintain the structure of their host; or certain poisons may 
be introduced within a living body, more or less completely inhibiting 
its energy. 

In these and in other ways can be produced a variety of deviations 
from the standard type of structure and function that would be other- 
wise obtained through the unimpeded activity of the organizing forces 
that are concerned with the evolution of life. Such deviations, if slight, 
may be disregarded ; but when considerable in amount they constitute 
a state that, if progressive, is known as disease. 

Such variations from the normal type may progress for a time, and 
may be then arrested, leaving as their permanent result a stable change 
of structure and function that is called the consequence of disease — 



ORGANIZATION OF THE BODY. 19 

e.g., ulceration, followed by cicatrization. In certain cases, upon the 
return of favorable conditions, the forces of organization may resume 
their sway throughout the body ; morbid processes cease ; their con- 
sequences are removed, and health is restored — e. g., pneumonic infil- 
tration of the lung, and subsequent removal of the exudation. 

From these and from similar considerations it appears that health 
may be defined as the condition of structure and function that most 
perfectly fulfils the purpose for which an organism exists. In like 
manner it may be concluded that every extraordinary departure from 
the normal structure and function of the living organism constitutes 

DISEASE. 

It is inconceivable that any considerable disturbance of organic func- 
tion can exist without an underlying perversion of structure. When 
such structural changes become evident to the senses, the accompanying 
disease is said to be organic in its character. But when the structural 
change is of such an infinitesimal character that it escapes detection, 
the abnormal function is called a functional disease. 

The indications by which the existence of disease is recognized are 
termed symptoms. These are subjective when of such a character that 
they can be demonstrated only by reference to the sensations and state- 
ments of the patient himself; they are said to be objective when they 
admit of observation on the part of others. Indications that may be 
noted by the eye, or ear, or the sense of touch, are known as physical 
signs — a term that is usually applied to symptoms that are afforded by 
inspection, auscultation, percussion, and palpation of the thorax and 
abdomen. 

Diagnosis is the act of decision with regard to the location and nature 
of a given disease. Differential diagnosis consists in the differentiation 
of a disease from others by which it is closely resembled. This process 
is sometimes called diagnosis by exclusion, when the diagnosis is reached 
by a rational exclusion of all other diseases that might possibly be 
present in the case under consideration. 

Pathology is the comprehensive statement and explanation of morbid 
processes. That department of pathology which deals with the struc- 
tural changes that are produced by disease, is termed pathological 
anatomy. 

Etiology treats of the causes of disease. These are usually divided 
into predisposing causes and exciting causes. 

Prognosis is the statement of the results of experience regarding the 
course and termination of disease. 

Treatment is concerned with the remedial management of disease. 



20 PRELIMINARY CONSIDERATIONS. 



CHAPTER II. 

GROWTH AND DEVELOPMENT. 

An investigation of the reproductive process exhibits the transfor- 
mation of unicellular germs into complex structures that are built up 
out of elementary parts, of which many resemble the parent cell, while 
others are widely differentiated from the original germ. Witness the 
difference between the cells of a striated muscular fibre and the embry- 
onic cells of the ovum out of which they have been perfected. This 
process of orderly deviation from the original form is called development. 
It is the process by which the different tissues and organs of the foetal 
embryo are produced. 

Growth, on the other hand, is the result of an increase in the number 
of similar elements in an organ or tissue. Development, therefore, 
precedes growth. Mere increase in size must not be confounded with 
growth, however, since enlargement may be caused by simple expan- 
sion of constituent cells without multiplication of their number — e. g., 
in the salivary glands the secreting cells vary in size according to the 
state of their activity, and the whole gland may be distended and 
enlarged by the products of secretion, though the number of its cells 
may not be notably increased. In like manner the bulk of the sub- 
cutaneous areolar tissue may be greatly enlarged by an accumulation 
of fat within its cells, even though their actual number be considerably 
diminished during the process. 



CHAPTER III. 

REGRESSIVE DISTURBANCES OF NUTRITION. 

The process of development and of growth cannot go on indefinitely. 
Sooner or later every organism reaches its appointed limit in time and 
space. The life of the body may be suddenly terminated by the arrest 
of its functions. This is death. Dissolution, the opposite of evolution, 
now commences. The tissues which have been developed, and which 
have grown under the protective and coordinating influence of vital- 
izing forces, now undergo a retrograde process, and are speedily resolved 
into their elementary molecules. 

The processes of regressive metamorphosis are not limited, however, 
to the dead body. During the life of every organism individual por- 
tions of its structure are suffering disintegration, through which they 
cease to live, and are cast out again into the world of non-living matter. 



REGRESSIVE DISTURBANCES OF NUTRITION. 21 

This process of local death and disintegration is termed necrosis. It 
may involve a considerable portion of the body ; it may be restricted 
to a single cell ; or it may involve only the minutest portions of a 
cellular structure. 

The causes of necrosis may be mechanical, as when a portion of the 
skin is destroyed by pressure or by violence ; chemical when similar 
destruction is wrought by the action of a chemical agent, like sulphuric 
acid. Excessive cold and heat are also fatal to the tissues that are 
exposed to their influence. Even the comparatively slight elevation of 
temperature that occurs in certain fevers is sufficient to produce the death 
of protoplasm in many of the living cells of the body. The life of the 
tissues may be also destroyed through failure of the supply of nutri- 
ment that should be furnished by the blood. In this way death quickly 
follows when the blood is deprived of oxygen. 

In highly developed organisms like the human body, the life of cer- 
tain tissues — e.g., the muscles — is dependent upon their connection 
with the central nervous organs of the body ; and when that connec- 
tion is interrupted either by disease or by injury, the death of such 
tissues speedily follows. When such interruption of innervation is 
concurrent with pressure upon the enfeebled tissues, gangrene rapidly 
follows — e.#.,the bedsores which occurs during severe forms of fever — 
diseases of the spinal cord, etc. 

Coagulative necrosis is a condition in which sudden arrest of the 
circulation causes precipitation of fibrin in the form of minute granules, 
either in the blood and lymph, or in the protoplasm of the cells, or in 
the products of exudation, causing a swelling and induration of the 
tissues that are involved. 

Caseation is a form of necrosis in which the constituents of the tissue 
become transformed into a cheese-like mass. This process is frequently 
observed in the lungs during the progress of tubercular disease. The 
affected tissues having been caseated, the necrotic mass is sometimes 
infected with pyogenic bacteria which produce suppuration, softening, 
and disintegration, with subsequent discharge of the broken-down sub- 
stance, producing a cavity in the lung or other affected organ. 

Gangrene is the putrefaction of a portion of the body. When the 
gangrenous tissues are exposed to dry air they frequently undergo 
dessiccation, constituting what is known as dry gangrene or mummifi- 
cation. This process is usually observed in the extremities, involving 
the toes or the fingers, as a consequence of senile changes in the arte- 
ries, by which the supply of blood is arrested. When the necrotic 
tissues are abundantly infiltrated with liquids they become extensively 
invaded by the microorganisms of putrefaction, and through their action 
the dead or dying tissues are rapidly decomposed with the evolution of 
offensive gases, constituting what is described as moist gangrene or 
sphacelus. 

It sometimes happens that particular organs or portions of the body 
fail to grow according to the normal laws of growth, so that they remain 
permanently smaller than their fellows This condition of imperfect 
and deficient enlargement is termed hypoplasia. The condition is 
usually congenital, though it is sometimes manifested as a consequence 



22 PRELIMINARY CONSIDERATIONS. 

of insufficient nutrition, or of causes that escape explanation — e.g., 
chlorotic patients frequently exhibit a deficiency in the size and growth 
of the vascular organs of the body ; or perhaps their sexual organs 
never attain to full development. 

Atrophy is the shrinkage or destruction of a tissue or organ which 
had previously attained its normal growth. A certain amount of 
atrophy is common to the entire organism in the later years of 
advanced life, constituting senile atrophy. A similar but earlier 
atrophy is witnessed in childhood in the case of the thymus gland, 
and in the middle life of women on the part of their reproductive 
organs at the menopause. When muscles, bones, glands, and other 
tissues are placed in a condition of inactivity they undergo atrophy 
from disuse. When similar organs are disconnected from the spinal 
cord by injury of the peripheral nerves, they undergo a neurotic 
atrophy, which is the consequence of the suppression of nervous 
impulses by which their nutritive processes are normally controlled. 
The arrest or the diminution of the supply of blood that should be fur- 
nished to a given organ or portion of the body, is followed by atrophy 
through partial starvation ; though this process frequently terminates 
in actual degeneration. The best examples of atrophy are furnished 
by the shrinkage and displacement of tissue that occur in chronic 
inflammation of the liver and the kidney, in amyloid infiltration of 
those organs, and in cirrhosis of the liver, by which the secreting cells 
of the gland are compressed through contraction of the inflamed con- 
nective tissue. Atrophy in these cases results from direct and con- 
tinuous pressure, and is termed pressure atrophy. When a tissue is 
subjected to intermittent compression, it becomes hypertrophied, instead 
of undergoing atrophy. 

As a consequence of regressive changes in the nutrition of a tissue, 
the constituent cells of the affected part exhibit various forms of degen- 
eration. Of these the simplest variety is termed cloudy swelling. 
(Fig. 1.) This consists in an accumulation of minute granules of albu- 
min within the substance of a cell, causing it to 
Fl »- 1- swell, assume a cloudy appearance, and lose the 

clear definition of its outline. This process is 
most conspicuous in the parenchymatous cells of 
the large glandular and muscular organs. It is 
"•-i •-' produced by excessive bodily temperature, by in- 

flammation, by infective processes, and by certain 
Cloudy swelling of liver poisons. The affected cells appear to lose their 
cells, x 300. (Ziegler.) nuclei, which, however, are merely veiled by the 
multitude of granules in the protoplasm. Some- 
times the degenerating cells imbibe large quantities of water, constitu- 
ting what is termed hydropsical degeneration. 

Fatty degeneration consists in the destruction of the cell and its 
appendages by the conversion of its protoplasm into fatty matter. (Fig. 
2.) This differs from fatty infiltration in the fact that it is a necrotic 
process, while infiltration with fat is a mode of physiological develop- 
ment. Cells that have experienced fatty degeneration are called com- 
pound granular corpuscles. In appearance these resemble cells that 



REGRESSIVE DISTURBANCES OF NUTRITION 



23 



have undergone cloudy swelling, but they are larger, and the granules 
in their protoplasm are minute particles of fat instead of albumin. 
Cloudy swelling frequently precedes fatty degeneration. The degenera- 
tive process is connected with changes in the blood and in the cells by 



Fig. 2. 



**-**@£J^^ 




Fig. 3. 



f*~.-3a 



Fatty degeneration of heart, a. Rupture of the heart with diseased arteries, b. Pur- 
pura, c. Pericarditis, d. Ordinary form. e. Uterine muscular fibres a week or two after 
delivery. /. Granule cells, g. Cancer cells. (Bristowe.) 

which the transportation of oxygen and its assimilation are hindered. 
Fatty degeneration is, therefore, a common consequence of anaemia, and 
of poisoning with phosphorus, chloroform, iodoform, arsenic, the mineral 
acids, etc. 

Colloid degeneration consists in the transformation of protoplasm 
into a homogeneous jelly-like substance, resembling glue. (Fig. 3.) 
This form of degeneration is found in cancerous 
tumors, in cystic ovarian tumors, and it character- 
izes the hyaline casts that are thrown off from the 
tubules of the kidneys in certain diseases. 

Mucoid degeneration is a process by which the 
affected tissues are transformed into a jelly-like 
substance containing mucin. It usually occurs in 
tumors that involve the connective tissue, such as 
fibrous, sarcomatous, cartilaginous, or fatty tumors. 

Amyloid degeneration, sometimes termed waxy, 
lardaceous, or albuminoid infiltration (Fig. 4), is 
caused by the infiltration of an organ or tissue with 
a nearly solid substance that is identical in compo- 
sition with albumin, and is stained mahogany-brown 
by a solution of iodine. Structures that have been thus infiltrated are 
rigid, elastic, somewhat enlarged, and waxy in appearance. The form 
of degeneration is most frequently encountered in the liver, kidneys, 
spleen, stomach, intestines, heart, arterial walls, lymphatic glands, and 
sometimes in the tissues of the lungs, skin, and supra-renal capsules. 
Similar masses of infiltrated matter are found in the central nervous 
organs in various diseases of the nervous system, constituting what are 




Colloid degeneration 
of muscle. X 250. 
(Bristowe.) 



24 



PRELIMINARY CONSIDERATIONS 



called amyloid or colloid bodies. Nothing positive is known regarding 
the nature and cause of amyloid degeneration. It generally accom- 
panies tubercular and syphilitic processes, prolonged suppuration, 
chronic diarrhoea, wasting diseases, and leukaemia. 

Fig. 4. 




Lardaceous degeneration of kidney, a. Section of tubes or medulla, b. Malpighian bod} 
and afferent vessel. X 250. (Bristowe.) 



Hyaline degeneration chiefly involves the connective tissue, and 
closely resembles in its general appearance the result of amyloid de- 
generation ; but the products of hyaline degeneration differ from amy- 
loid matter, since they are not colored by iodine, and do not display the 
histological features of mucoid degeneration. 

Calcification is a process by which degenerated tissues become infil- 
trated with insoluble salts of calcium and magnesium. This process 
frequently occurs in the coats of the arteries (Fig. 5), in various tumors 
and in cartilaginous tissues, as a consequence of old age. The process 
is often witnessed in tubercular masses that have undergone caseation. 
Similar concretions are sometimes formed in the ducts of the pancreas, 
salivary glands, prostate glands, crypts of the tonsils, intestines, urinary 
passages, etc. An allied form of calcification is often witnessed about 
the joints in old cases of gout. (Fig. 6.) 

Pigmentary degeneration. In many parts of the body the con- 
nective tissue and the epithelial structures contain pigment as a normal 
constituent : but as a consequence of various morbid processes the amount 
of pigment may be greatly increased, or it may be deposited where it 
should not exist. Pigments are either derived from the coloring matter 



REGRESSIVE DISTURBANCES OF NUTRITION 



25 



of the blood, or they may be introduced into the organism from the 
external world. 

Pigmentation with haemoglobin frequently occurs after death, when 
the red blood- corpuscles have become disintegrated. The blood serum 
then contains haemoglobin in solution, and the lining membranes of the 
heart and larger arteries become stained by infiltration with this form 
of coloring matter. 

Fig. 5. 




Calcareous degeneration of cerebral vessels. X 250. (Bristowe.) 
Fig. 6. 




Cartilage of joint infiltrated with urate of soda. X 250. (Bristowe.] 



The haemoglobin of old clots, such as are found in the brain or in 
aneurismal cavities, is frequently transformed into hcematoidin, which, 
by its accumulation, occasions pigmentation of the adjacent tissues. 

(Fig- 7.) _ 

Melanine pigmentation, or melanosis, is another form of pigmentation 
that occurs in the degeneration of connective tissue, and in new 
growths, especially when they involve parts that are already pigmented. 



26 PRELIMINARY CONSIDERATION'S. 

This is very conspicuous in Addison's disease, where those portions of 
the skin that are normally colored become very deeply darkened by 
the melanotic deposit. In intermittent fever the blood, the spleen, the 
liver, and the adjacent organs, become highly charged with melanine. 




Pigmental degeneration with haematoid crystals. X 250. (Bristowe.) 

Lutein pigmentation. Lutein is a substance closely related with 
haematoidin. It exists in the yolk of the egg and in the corpus luteum 
of the ovary. 

Bile pigmentation. The coloring matter of the bile frequently stains 
the tissues when obstruction of the common bile-duct causes its absorp- 
tion into the circulating fluids of the body. It also stains the peri- 
toneal surfaces in the vicinity of a distended gall-bladder. The mucous 
membrane of the stomach and of the intestines may be also pigmented 
by excessive discharge of bile into those organs. 

Purulent pigmentation. Pus sometimes assumes a blue, red, orange, 
green, or yellow color through the presence of microbes that secrete 
colored pigments. 

Pigmentation with substances, derived from the external world is 
often witnessed as a consequence of inhalation of minute particles of 
carbon, which are deposited in the walls of the air vesicles of the 
lungs. The long-continued administration of nitrate of silver may lend 
to a slate-colored pigmentation of the skin. Arsenic also sometimes 
causes a brown stain in the substance of the integument. 

Cystic degeneration consists in the formation within a tissue or organ 
of a cavity surrounded by a connective-tissue capsule or other form of 
limiting membrane. Such cysts may be either simple or multilocular. 
They are most frequently produced by the occlusion of a normal 
glandular canal, constituting what is termed a retention cyst. The 
follicles of the thyroid gland or of the ovary sometimes undergo cystic 
degeneration as a consequence of excessive secretion within their 
cavities. The contents of a cyst are determined by the character of its 
wall, e. g., glandular cysts contain the more or less modified secre- 
tions of the gland. Sometimes cysts are produced by the process of 
softening and liquefaction of a circumscribed portion of an organ. 
Such cysts are found occasionally in the brain. Foreign bodies and 
parasites that have found their way into the tissues are frequently en- 
capsulated by a cystic growth of connective tissue around the intruding 
body. 



PROGRESSIVE DISTURBANCES OF NUTRITION. 27 



CHAPTEE IV. 

PROGRESSIVE DISTURBANCES OF NUTRITION. 

Hypertrophy. When an organ or tissue has actually exceeded 
the normal standard of growth, through increase in the size of its con- 
stituent cells, it is said to be hypertrophied. Witness the increase 
that occurs in the muscles of a laborer. Hypertrophy may thus result 
as the consequence of excessive normal function, but it may be also a 
consequence of disease, as can be observed in the increase of muscular 
tissue in the heart when its valves are deficient. If, however, the 
enlargement be due to an increase in the number of the constituent 
cells of an organ or tissue, the process is termed hyperplasia. Again, 
hypertrophy must not be confounded with mere enlargement. The 
size of a fatty liver or kidney may be greatly increased by the presence 
of fat within its cells, but unless the number of liver cells be actually 
raised beyond the normal standard, there is no hypertrophy. The 
organ is rendered bulky by fatty infiltration of its cells, which, very 
likely, have been actually diminished in number during the process. 
Local hypertrophies that do not involve an entire organ, or tissue are 
called neoplasms. 

The process of hyperplasia is dependent upon the multiplication of 
the cellular elements of the parts in which a progressive disturbance 
of nutrition has been initiated. The process of multiplication, termed 
cellular proliferation, consists in the formation of new cells by sub- 
division of the original elementary parts of the tissue. The nuclei of 
the cells divide into two or more masses, which become the central 
nuclei of the new generation. Division of the nucleus is usually fol- 
lowed by a corresponding division of the perinuclear protoplasm, so 
that the parent cell splits up into tw T o or more completely developed 
cells, which in turn undergo similar subdivision. In this way the 
process of multiplication proceeds with great rapidity. Sometimes, 
however, though the nuclei undergo extensive subdivision, the sur- 
rounding protoplasm does not exhibit a similar change. Such poly- 
nucleated cells become greatly enlarged, and are called giant cells. 
(Fig. 8.) They are frequently observed in the course of tuberculosis 
and in other pathological processes. 

The causes of cell proliferation and hyperplasia are connected with 
the quantity and quality of the nutriment that is furnished by the 
blood for the nutrition of the tissues. An increased supply of whole- 
some nutriment favors growth, but does not necessarily produce 
hyperplasia. In like manner the normal function of a tissue or organ 
is favorable to its growth, but when an abundant supply of nutriment 
is associated with extraordinary excitement and excessive functional 
activity, the limit of simple hypertrophy may be easily transgressed 
and hyperplasia begins. The presence of certain substances in the 



2^ PEELIMIXARY CONSIDERATIONS. 

blood s os abnormal excitement, and tbus produces subdr 

and multiplication of the constituent cells that are exposed to irrita- 
tion ; but if such irritation be [ r, the hyperp] si 

- 38, and inflammatory or regressive changes of a degenerative 
character are manifested. Thus, when one k: •:■: r si 
the other kidney is therefore compelled to excrete urine for the entire 
t : ecomes greatly enlarg s : but if at the same 

time the blood that circulates in the organ should contain an 

ting alcohol, or t I from bacterial - T p er_ 

plast tissues underg ;ess of regressi v 

- - : their elementary parts 

Fig. s. 




— 



Tubercle showing — ^, giant cells with prol i . . rpithelioid cells. P 

Hyperplasi is - .rtimes dae :: :Lt : :he normal re- it- 

ance by which, under ordinary eircunistanc— sell prolifera- 

tion is prevent! . in granulating ulcer the rapid growth of 

granulations is largely due to the fact that the bloodvessels arc 
and released from the [ g ire of the skin. So soon as the 

ulcerous surL vered by a cicatricial tissue the hyperplastic 

.ses. 

Men:::.. 5 of the fact thai impregnation of the blood 

with certain poison snch as alcohol or bacterial toxines. 

may produce degenerative changes in the tissues. It is also true that 
and other similar pc y cause hyperplasia if they be not 

present in quantity sufficient to destroy cell life. Thus the moderate, 
but persistent use of alcoholic gee rids to hyperplasia of the 

conn-. — ue in the walls of the stomach and in the liver. In 

likemani. as and staphylococcus pyogenes 

excite a modified r ~ died inflammation, in which hyperplasia and 

_ eration an 

When hyperplae ira in a compound organ, its component 

tissues are often very differently affected by the process. Thus in the 



TUMORS. 29 

liver, the connective tissue frequently undergoes extensive hyperplasia, 
while the parenchyma of the gland either undergoes no increase or is 
actually subjected to atrophy as a consequence of compression by the 
hyperplastic connective tissue. Such unequal manifestations of the 
tendency to cell proliferation are common consequences of chronic 
inflammation, and are a very fruitful source of dangerous disease and 
destruction of the organs that are thus invaded. 

The regenerative processes by which wounds or other defects are 
repaired, sometimes exert a similar evil effect upon the structures in 
which the process of repair has been effected. The formation of 
cicatricial tissue is sometimes a source of great embarrassment to the 
function of an organ. Since the newly-formed tissue does not replace 
that which has been destroyed, its contraction may occasion great 
deformity and constriction of the remaining tissues, e. g., the forma- 
tion of cicatricial tissue after cerebral hemorrhage, or in the curtain of 
a cardiac valve, may permanently disable the brain or the heart. The 
formation of such cicatricial tissues, which though normal in character 
do not replace the elements that have been destroyed, is termed hetero- 
plasia. Other conspicuous examples of heteroplastic growth are fur- 
nished by the formation and growth of tumors. 

Under certain circumstances a transformation of one tissue into 
another may be witnessed. This process is termed metaplasia. The 
connective tissues exhibit the most conspicuous examples of such trans- 
formation. Thus the mucous tissue, or the subcutaneous areolar 
tissue, or a lymph-adenoid tissue may be transformed into fatty tissue. 
Cartilage may also be transformed into mucous tissue, or it may 
become infiltrated with earthy salts and converted into bone. In 
chronic inflammation of the mucous membranes, cylindrical epithelium is 
often in like manner replaced by or changed into pavement epithelium. 



CHAPTEE V. 

TUMOKS. 

In the present state of science it is impossible to furnish an adequate 
and comprehensive definition of the word tumor, since the causes and 
growth of such masses are not yet understood. From a clinical point 
of view, however, a tumor may be defined as a mass of tissue developed 
where it does not belong, and manifesting a tendency to increase and 
to become permanent. 

Tumors are formed by the multiplication of normal tissue cells, con- 
sequently there may be as many varieties of tumors as of the tissues 
themselves ; osseous tumors are developed from the elements of bone ; 
fibrous tumors from fibrous tissues ; enchondromatous growths from 
cartilage : and myomas from muscular fibres. The structure of such 
tumors is said to be typical. When tumors are developed out of 



30 PRELIMINARY CONSIDERATIONS. 

undifferentiated embryonic cells, they are termed proto-typical growths, 
to indicate their origin from embryonic elements. When tumors are 
formed partly from embryonic cells and partly from tissues that have 
been already differentiated, the new growth is said to be of a mixed 
character. Besides these forms must be recognized tumors that con- 
tain rudimentary foetal structures ; these have their origin apparently 
in a misplacement of reproductive elements. 

It has been recently ascertained that certain forms of epithelioma 
(warty growths) are due to the action of protozoa which develop in the 
tissues. It is highly probable that other species of tumor may be 
produced through the activity of other parasites ; but in the present 
state of our knowledge this opinion is purely hypothetical. 

An ingenious hypothesis was formulated by Cohnheim, who en- 
deavored to show that every tumor had its origin in a disorder of the 
evolution of the embryo. As a consequence of vicious organization, a 
group of embryonic elements might be retarded in their development 
until a certain period in the life of the individual had been reached ; 
or until by reason of some accidental injury they were excited to mul- 
tiplication ; or by such injury were released from the restraining 
influence of the adjacent normal tissues. In many instances, undoubt- 
edly, the exciting cause by which was aroused the proliferating energy 
of a latent mass of embryonic tissue must necessarily elude discovery, 
being dependent upon processes that are not yet understood. This 
hypothesis affords an exceedingly plausible explanation for the growth 
of tumors that are composed of elements which differ from the tissues 
in which they originate. When a cartilaginous tumor develops in a 
bone, it seems highly probable that the embryonic elements of cartilage 
were originally included in the osseous tissue. But, despite the mul- 
titude of facts by which the argument is supported, it must be admitted 
that it leaves many things still unexplained. It will be necessary to 
wait for additional information before a complete theory of the genesis 
of tumors can be constructed. 

The rapid growth of a tumor is due to the multiplication of its 
cellular elements, which divide and subdivide with great rapidity. 
The mass is permeated by numerous bloodvessels and lymphatic canals, 
which in many neoplasms furnish an abundant circulation throughout 
the entire growth. Tumors, like malignant cancers, that consist 
chiefly of embryonic tissue, are provided with bloodvessels with very 
thin walls that are easily ruptured, and give origin to more or less 
copious hemorrhage. When a tumor is chiefly formed out of differ- 
entiated tissue, like a fibroma or a fatty tumor, the vascular walls are 
dense and are not easily ruptured. 

The elements of which a tumor is composed frequently undergo 
degenerative processes, such as fatty, colloid, mucous, pigmentary, or 
calcareous degeneration. Colloid degeneration is frequently observed 
in epithelial and cartilaginous tumors and in sarcoma. Calcareous 
Infiltration is sometimes discovered in cartilaginous and fibrous tumors, 
and in the endothelial tumors of the dura mater, constituting what is 
termed psammoma. 

The growth of a tumor is usually continuous, but in certain cases of 



TUMORS. ' 31 

cancer the volume of the mass may for a time diminish, though it never 
entirely disappears. 

Many neoplasms present a clearly defined boundary, but it is often 
difficult to determine the limits of a tumor, especially when dealing 
with epithelial growths whose elements multiply rapidly. The adjacent 
tissues become extensively invaded by prolongations of newly formed 
tissue which follow the lymphatic vessels, and push aside the normal 
structures of the part. In this way the lymphatic glands in the 
neighborhood of the new growth are frequently invaded by the morbid 
process. Minute particles of the tumor are sometimes transported to 
a distance through the medium of the circulation, and become centres 
of infection remote from the original growth. In this way are fre- 
quently originated secondary tumors, which may develop and enlarge 
long after the removal of the primitive tumor from which they were 
derived. When a serous membrane is thus invaded, it sometimes be- 
comes covered with minute nodules that in appearance considerably 
resemble miliary tubercles (miliary carcinoma). 

From a clinical point of view tumors may be considered as benign 
growths or as malignant growths. A benign tumor enlarges slowly, 
does not ulcerate nor disseminate its elements throughout the organism, 
and, if extirpated, is not reproduced. Malignant tumors exhibit ex- 
actly opposite characteristics. The malignancy of a tumor is con- 
spicuous in proportion to the embryonic character of its elements, and 
to the vascularity of its structure. 

The peculiar cachexia and anaemia that accompany the growth of 
malignant tumors are ascribed to a general poisoning of the system 
with the products of morbid cell growth ; but, perhaps, they may be 
due to the diffusion of the secretions of yet undiscovered parasitic 
agents, which possibly are concerned in the formation of such neo- 
plasms. 

The classification of tumors varies with the progress of knowledge. 
If ever the mystery that veils the origin and development of neoplastic 
growths shall be dissipated, it is probable that an entirely new method 
of classification will be found necessary. At present the histological 
method, though not without its disadvantages, is found convenient. 
The following table from Hallopeau exhibits at a glance the present 
state of information regarding the nature and relations of tumors : 

I. Simple Tumors. 

1. CONNECTIVE-TISSUE TUMORS. 

A. Typical form*. B. Proto- typical forms. C. Mixed forms. 

a. Fibroma. a. Round-celled sarcoma. a. Fibro-sarcoma. 

b. Myxoma. b. Spindle-celled sarcoma. b. Myxo-sarcoma. 

c. Endothelioma. c. Alveolar sarcoma. c. Glio-sarcoma. 

d. Cholesteatoma. d. Giant-celled or angioblas- (/. Lipomatous sarcoma. 

e. Glioma. tic sarcoma. 



/. Lipoma. 



2. CARTILAGINOUS TUMORS. 



A. Typical forms. B. Mixed forms. 

Enchondroma. Chondro-sarcoma. 



32 



PRELIMINARY CONSIDERATIONS. 



3. OSSEOUS TUMORS. 



A. Typical forms. 
Osteoma. 



B. Mixed forms. 
Osteosarcoma. 



4. VASCULAR TUMORS. 



A. Typical forms. 

a. Angioma. 

b. Lymphangioma. 

c. Lymphoma. 



B. Mixed forms. 
a Angio-sarcoma. 
6. Lympho-sarcoma. 



O. MUSCULAR TUMORS. 



A. Typical forms. 
a. Rhabdo-myoma. 
6. Leio-myoma. 

6. EPITHELIAL TUMORS 



B. Proto-typ ica 1 1 fo rim. 
Myo-sarcoma. 



A. Typical forms 

a. Pavement-celled epithelioma. 

b. Papilloma. 

c. Cylindrical-celled epithelioma. 

j a j f acinous. 

d. Adenoma ] tubular> 

e. Sebaceous cysts, simple and dermoid. 
f. Serous, mucous, and colloid cysts. 



B. Proto-typicalforms. 

a. Carcinoma. 

b. Cylindroma. 



i . NERVOUS TISSUE TUMORS. 



A. Typical forms. 
Neuroma. 



B. Proto-typical forms. 
Neuro-glioma. 



II. Compound Tumors. 



Teratoma 



Fibroma. Fibroma consists chiefly of fibrillary connective tissue. 
It exists in two forms : the hard fibroma, composed of resistant fibrous 
tissue like that of a tendon ; and the soft fibroma, of which the struc- 
ture resembles that of the subcutaneous areolar tissue. (Fig. 9.) Both 



Fig. 9. 




Fibroma from surface of spleen. X 350. (Bristowe.) 



varieties grow slowly and are non-malignant. They may become in- 
flamed and ulcerated, and undergo various degenerative processes. 
They usually occur in elderly subjects, and are located in the skin and 
in the areolar tissue beneath the integuments. They are also found in 
the tendons, aponeuroses, nerves, and ovaries. 

Myxoma. Myxomatous tumors consist largely of mucous tissue, 
like that which exists beneath the skin of the foetus, and in the 
umbilical cord. They contain a few round cells, spindle cells, and 
fibrils. (Fig. 10.) The tumor is usually developed in the subcutaneous 



TUMORS. 



S3 



areolar tissue, or in the nervous system. Hydatid moles are similarly 
constituted. Sometimes the growths consist not only of mucous tissue, 
but also of other tissues, forming mixed tumors to which may be 
applied the name myxo-sarcoma, myxo-fibroma, myxo-lipoma, etc., as 
the case may be. Sometimes they contain cavities, and are then 
described as cystic myxomas. 

Fig. 10. 




Myxoma, (a. H. Arnott. b. Cornil and Ranvier.) 
Fig. 11. 




Endothelioma of the dura mater, showing the alveolar arrangement of the cells. 
X 250. (Hallopeau.) 

Endothelioma. This species of tumor has been confounded with 
sarcoma and with epithelioma. It consists chiefly of large flat cells 



34 



PRELIMINARY CONSIDERATIONS. 



containing one or two nuclei. (Fig. 11.) Associated with these ele- 
ments are sometimes found calcareous deposits, hence the term psam- 
moma that has been assigned to these growths when they develop in 
the endothelium of the dura mater. Endothelioma is sometimes 
developed upon the peritoneum, and it may grow wherever endothelial 
tissue exists. 

Cholesteatoma develops chiefly at the base of the brain, and has its 
origin in the pia mater. It consists of concentric layers formed of flat 
cells of an endothelial character. 

Glioma is a benign tumor that consists of a reticulated tissue which 
resembles the neuroglia of the brain. It develops chiefly in the brain, 
spinal cord, retina, optic, and auditory nerves. 



Fig. 12. 



Fig. 13. 




wmmm 



Round-celled sarcoma of lung. X 400. (Payne ) 
Fig. 14. 






^A> 



If' 

... ... _.. 



1 



P 



Giant-celled sarcoma. X 300. (Hallopeau.) Alveolar sarcoma. X 250 (Giessk> 




k.j 



Lipoma exists as a benign tumor, often multiple in number, in the 
subcutaneous, submucous, or subserous tissues of the body. It con- 
sists chiefly of fatty tissue. 



T U M R S . 



30 



Fig. 15. 



Sarcoma. There are many varieties of sarcoma. In certain forms 
of the tumor it is composed chiefly of embryonic cells, constituting a 
proto -typical sarcoma. In other cases the constituent cells exhibit 
transitional forms intermediate between the embryonic cell and the 
more highly differentiated elements ; such tumors are termed meta- 
typical. 

Mixed forms are not uncommon, in which embryonic cells .are asso- 
ciated with completely differentiated tissue cells. 

The round-celled sarcoma consists of small round cells inclosed in a 
nearly amorphous stroma. (Fig. 12.) In the bones the round cells are 
sometimes separated into groups by fasciculi consisting of spindle cells, 
constituting what is termed alveolar sarcoma. 
(Fig. 13.) This variety closely resembles 
in its microscopical appearance that of car- 
cinoma, but its alveolar spaces contain a deli- 
cate fibrillary network which is wanting in 
the alveolar spaces of carcinoma. 

The giant-celled variety of sarcoma (Fig. 
14) may be recognized by the presence of 
large polynucleated cells in its substance. 

The spindle-celled sarcomas contain nu- 
merous fascicles of spindle-cells separated by 
an amorphous substance. (Fig. 15). Some- 
times sarcomatous tumors contain haemoglo- 
bin derived from extravasated blood. It is 
possible that such tumors have a parasitic 
origin, and this view is rendered somewhat 
probable by the retrogressive changes that 
are sometimes exhibited by them. 

Melanotic sarcomas owe their color to the fact that they have their 
origin in pigmented tissues, such as the choroid, or the pigmented cells 
of the skin. 

In many instances sarcoma occurs in association with other varieties 
of connective-tissue new growth. Such tumors are designated as 
fibro-sarcoma, myxo-sarcoma, glio-sarcoma, chondro-sarcoma, osteo- 
sarcoma, angio-sarcoma, lympho-sarcoma, etc. 

Sarcoma is sometimes benign and sometimes malignant. The lower 
the grade of its organization the greater the tendency of the tumor to 
malignity. 

Enchondroma. Cartilaginous tumors exhibit all the varieties of 
cartilaginous tissue (Fig. 16), and in many cases the cartilaginous neo- 
plasm is associated with other forms of connective-tissue new growth, 
constituting chondro-fibroma, chondro-sarcoma, osteo-chondroma, etc. 
Enchondromatous tumors are usually benign, but sometimes they as- 
sume malignant characteristics. 

Osteoma. Osseous tumors are non-malignant growths that occur 
usually in the bones, and occasionally in the dura mater, in the apo- 
neuroses, and in the muscles. They consist of osseous tissue, and are 
of variable density. Sometimes the tumor consists of a cancellated 
bony substance, and is termed spongy osteoma. It may consist of 




Spindle-celled sarcoma. 
( Virchow.) 



36 



PRELIMINARY CONSIDERATION'S 



ordinary solid bony material, or it may be condensed and ivory-like, 
constituting what is termed an eburnated osteoma. In osteo-sarco- 
matous tumors the embryonic condition of the osseous cells is persistent. 



Fig. 16. 




Chondroma, a. Section of growth. X 150. b. Calcifying cells. X 250. (Bkistowe.) 

Angioma is a tumor that consists chiefly of newly formed blood- 
vessels. It may be either a simple angioma, or a cavernous angioma. 
The simple angioma is usually found upon the skin of the face in 

Fig. 17. 






: 






t 



" . 






■., 



i 












ife 






^> 






Dilated capillaries from a telangiectatic tumor of the brain. X 150. (Zikgler.) 

young children, constituting what is termed a vascular ncevus. It 
is occasionally encountered in the mucous membranes, in the brain, 
the bones, and mammary glands. It consists chiefly of dilated capil- 
laries with thick walls supported by connective tissue. (Fig. 17.) 



TUMORS. 



37 



The cavernous angioma is essentially a simple angioma in which the 
capillary vessels have become greatly distended. Such tumors are 
generally subcutaneous, but they are sometimes found in the liver, 
kidneys, spleen, uterus, bones, and muscles. 

Lymphangioma consists of dilated and hypertrophied lymphatic 
vessels. 

Lymphoma consists essentially in the hyperplasia of the constituent 
elements of a lymphatic gland. This must not be confounded with 
inflammatory enlargement of the lymphatic glands. It forms a non- 
malignant indolent growth, of which the glandular enlargements that 
accompany leukaemia and pseudo-leuksemia may be taken as a type. 
When the connective-tissue framework of the neoplasm exhibits exces- 
sive development, the tumor is called lymphosarcoma, and it often 
displays malignant characteristics. 

Myoma. Tumors that contain muscular elements are of two forms : 
rhabdo-myoma, a very rare species which has been observed only in 
the tongue and in the heart of newborn children ; aud leio-myoma, 



Fig. 18. 




Section through a leio-myoma. (Perls.) 

which, on the contrary, is not uncommon in the uterus (Fig. 18), 
prostate gland, alimentary canal, and other structures that contain 
smooth muscular fibres. These tumors are generally non-malignant. 

Myo-sarcoma. This form, which partakes of the characteristics of 
muscular tissue and of a sarcomatous growth, has been occasionally 
discovered in the kidneys or in the testicles, where its growth is prob- 
ably due to the inclusion of muscular elements during the period of 
fcetal development. 

Epithelioma. Epithelial tumors are developed from the epithelial 
tissue of the integument, or from that of the glandular organs of the 
body. Epidermal tumors, when constituted by the proliferation of the 
deep cells of the epidermis, are termed epitheliomas. (Fig. 19.) When 
they proceed from the papillary structures of the skin they are termed 
papillomas. 

Epithelioma occurs chiefly upon the lips, tongue, oesophagus, uterine 
cervix, vulva, and bladder. It consists of lobules that are separated 
by connective tissue The tumor frequently exhibits a warty appear- 



38 



PRELIMINARY CONSIDERATIONS. 



ance. It tends to ulcerate, and to invade the neighboring tissues, 
though its growth is often very tardy. Such neoplasms usually occur 
among old people, and are generally encountered upon the lower lip. 
often, apparently, as a consequence of local irritation produced by 
excessive smoking. 

Fig. 19. 




Epithelioma, a. Section of growth. X 250. b. Free cells. X 250. c. Free cells more 
highly magnified. X 450. Bristowe.) 

The papilloma is a non-malignant tumor that consists of epidermic- 
cells developed upon a connective-tissue base that is identical in its 
structure with a cutaneous papilla. Ordinary warts, which are papillo- 
matous tumors of parasitic origin, exhibit this papillary structure in a 
high degree of perfection. 

Fig. 20. 




Epithelioma of the stomach. -300. (Hallopkau.J 



Epitheliomatous tumors are sometimes developed upon the mucous 
surfaces of the body. Their mode of growth and their general struc- 
tare are analogous to that of the corresponding tumors of epithelial 
origin upon the epidermal surfaces of the body. (Fig 20.) 



T UJIORS. 39 

Cylindrical Epithelioma develops upon surfaces that are normally 
provided with cylindrical epithelium, e. g., the gastro-intestinal mucous 
membrane, and the glandular ducts that communicate with the intestine, 
also the uterine and olfactory mucous surfaces. 

These tumors invade the neighboring tissues, producing atrophy by 
compression ; and they also perforate the bloodvessels. They some- 
times undergo mucous or colloid degeneration, and they reproduce 
themselves in organs at a distance from the original focus of disease. 

The Adenomas are neoplasms developed from glandular tissue. The 
acinous variety represent the glandular pockets of the parent gland. 
Such tumors are found in the breast, in the sebaceous and sudoriparous 
glands, in the parotid, and about the fauces and pharynx ; they are 
generally of small size, and do not exhibit malignant characteristics. 
(Fig. 21.) 

Fig. 21. 

«.•.■' - v "•■ ■ . yuC 



1 

-• * ■'•' 

. . - -< 

'■■■'<}. 
ilft 



Alveolar adenoma of the mammary gland, a. Alveoli, b. Glandular duct. c. Con- 
nective-tissue stroma. X 240. (Ziegler.) 

The tubular adenoma is composed of cylindrical cells which represent 
the cylindrical cells of the tubular glands in the mucous membranes. 
This variety of adenoma is non-malignant, and exists in the walls of 
the stomach, intestine, and uterus. When thus developed in the uterine 
cavity, it constitutes what is known as a mucous polyp. 

The cystic variety of adenoma represents an exaggerated develop- 
ment of the glanduiar cavity of a secreting gland. The original 
glandular pocket becomes dilated and surrounded by thick walls that 
consist of cells that have in some degree departed from the original 
form of the glandular epithelium, but are still supported by a fundamental 
layer of undifferentiated glandular epithelium. The cavity of the tumor 
is filled with a liquid that somewhat resembles the normal secretion of 
the gland in which the neoplasm is developed. Similar perversions of 
growth are sometimes witnessed in connection with the sudoriparous 
glands of the skin. 



40 



PRELIMINARY CONSIDERATIONS. 



Ovarian cyst* are to be considered as constituting a variety of epithe- 
lioma. They are developed from the glandular epithelial investment, 
which puts forth processes that become hollowed and filled with liquid, 
like any glandular cavity whose excretory duct has been obliterated. 
(Fig. 22. ) The cavity of the cyst becomes divided into secondary cysts 



Fig. 







Cross-section of a multilocular cystoma from the ovary. £ natural size. | Ziegler. 

through the proliferation of the epithelial lining of the tumor : and the 
liquid contents of these multilocular cysts contain floating epithelial cells 
of various form and size. Sometimes the epithelial structure of the 
tumor is transformed into myxomatous tissue, constituting a colloid 
tumor: and mixed forms are sometimes observed. 

Carcinoma. A large number of the epithelial tumors are made up 
of undifferentiated epithelial cells that are simply agglomerated in 



Fig. 23. 




Cancer cells. X 500. (Bristowe. | 



irregular masses, without any semblance of organization like that which 
characterizes adenoma. Sometimes transitional forms are observed. 
These atypical tumors are commonly designated by the term cancer. 



TUMORS. 



41 



Many forms of sarcoma closely resemble carcinoma, but their alveoli 
contain endothelial cells instead of the epithelial elements that exist in 
carcinoma. 

The constituent cells of carcinoma exhibit a great variety of form, 
size, and structure. (Fig. 23.) They are generally very large, and 
contain one or more nuclei, together with granules of fat or of colloid 
substance. The stroma of the tumor is richly supplied with blood- 
vessels. The characteristic feature of carcinoma is its alveolar structure, 
in which the alveolar spaces are filled with epithelial elements, while 
the stroma consists either of fibrous tissue or of embryonic tissue. 
(Fig. 24.) When the alveolar walls are largely developed, and the 



Fro. 24. 




Scirrbus. X 250. (Bristowe.) 



alveolar spaces are small, the tumor acquires considerable density, and 
is termed scirrhus; when the alveolar walls are very thin, and the 
alveolar spaces are large, the tumor is designated encephaloid cancer. 
(Fig. 25.) Sometimes the tumor is exceedingly vascular, and its blood- 
vessels, though very large, are provided with walls whose structure is 
identical with that of the capillaries ; a condition that favors rupture and 
hemorrhage. 

Colloid carcinoma is characterized by the presence of gelatinous or 
colloid substance in the alveoli of the tumor. (Fig. 26.) 

Carcinomatous tumors are exceedingly malignant. They destroy the 
neighboring tissues, and extend themselves through the lymphatic 
channels into the neighboring lymphatic glands. In like manner their 
proliferating cells are transported by the blood into distant parts of the 
body, where they germinate and reproduce the original growth. Thus, 
the growth of a primary carcinomatous tumor in the stomach or in the 



42 



PRELIMINARY CONSIDERATIONS. 



pancreas may be followed by the appearance of secondary carcinomatous 
tumors in the liver. This process of secondary growth is especially 




Encephaloid cancer. X 250. (Bristowe.) 

frequent when the primary tumor consists chiefly of epithelial elements ; 
and for this reason it occurs more frequently in connection with enceph- 
aloid cancer than with the scirrhous form of the disease. 



Fig. 26. 




6 
Colloid cancer, a. Fibrous stroma, b. Cells, degenerating. X 250. (Bristowe.) 



The tendency of cancerous tumors to infiltrate the neighboring 
tissues with neoplastic elements is the principal cause of the reproduc- 
tion of such malignant tumors after they have been excised. The 



TUMORS. 



43 



germinal elements that remain in the unremoved tissues seldom fail to 
reproduce the disease. 

Cylindroma. A rare form of mixed tumor closely resembling carci- 
noma has been described under the name of cylindroma. It consists of 
alveoli containing cells like an ordinary carcinoma ; but among the 
cellular contents of the alveoli are developed translucent, homogeneous, 
spherical masses that resemble colloid substance and manifest a tendency 
to replace the normal cellular structure. 

Neuroma is a rare species of neoplasm. It may develop in the white 
or in the gray substance of the brain, where it sometimes attains to 
great magnitude. 

Fig. 27. 




Plexiform neuroma from the sacral region. Natural size. (P. Bruns ) 



The so-called neuromas that develop upon the peripheral nerves are, 
usually, either examples of fibroma or of myxoma; they sometimes, how- 
ever, contain nerve fibres. Occasionally a nerve exhibits multiple 
enlargements that suggest a resemblance to the venous dilatations 
observed in varicocele (plexiform neuroma). (Fig. 27.) 

Besides the neuromatous tumors of fibrillary structure, neuromas that 
are composed of ganglionic cells have been observed in the brain, in the 
ovary, 



and in the testicle. 



Teratoma. This term is employed to designate congenital tumors 
that contain foetal structures, such as bones, teeth, hair, skin, etc. 
Among these tumors are also included dermoid cysts. (Fig. 28.) The 
internal surface of such cysts exhibits an organization closely resembling 
that of the skin. The contents of the cavity are made up of sebaceous 
matter, hair, epithelial elements, and sometimes other foetal structures. 
The majority of these tumors are considered examples of the inclusion 
of rudimentary foetal elements that have been misplaced from their 
normal situation. When the tumor occupies the ovary, it is supposed 



44 



PRELIMINARY C O X 5 1 D E R A T I 



that two may have been simultaneously fecundated, but that 

during the pi jlopment one of them became enveloped in 




Portion of a dermoid cyst of the ovary, a. Cyst wall- b. Masses of fat and cutaneous 
^e c Hairs, d. Teeth. Natural size. ,'Zirglkr.) 

- lbstanee of the other, where its further progress could only be 

incomplete and imperii 



CHAPTER VI. 

DISORDERS INDUCED BY DISTURBANCE- OF THE 
CIRCULATION. 



When an excessive quantity of blood is for any reason supplied to 
an organ or tissue, the condition is termed but when, on 

the contrary, the blood-supply foils below the normal amount, local 
:ied. 

When hy] eraemia is caused by an inordinate afflux of blood, it is 
termed a ei n it is due to an obstruction to the 

ig ige of blood through the veins, it is termed passive hyperemia. 



DISORDERS FROM DISTURBANCES OF CIRCULATION. 45 

Active hyperemia frequently exists as a consequence of relaxation of 
the arterial walls under the influence of nervous excitement, as may be 
witnessed in the act of blushing. Similar vascular dilatation frequently 
occurs in connection with diseases of the nervous system, or as a con- 
sequence of reflex excitement. 

Passive hyperemia occurs whenever capillary stasis is produced by 
an obstacle in the course of the venous circulation. A typical example 
of this is furnished by cirrhosis of the liver, in which disease the hepatic 
capillaries are subjected to pressure, which hinders the outflow of blood 
from the portal system. The abdominal organs become, therefore, the 
seat of passive hyperemia. Still more extensive is the passive hyper- 
emia that is caused by those cardiac lesions which prevent the rapid 
flow of blood from the venae cave into the right side of the heart. 
When the mitral valve, for example, is deficient, passive hyperemia 
involves the entire pulmonary circulation and the whole venous system. 

A tendency to stagnation of the blood is often exhibited as a result 
of chronic relaxation of the venous walls. This may be observed as a 
consequence of malnutrition, anemia, and protracted illness. The 
hypostatic congestion that occurs in the dependent portions of the 
lungs during the later stages of typhoid fever belongs to this variety of 
passive hyperemia. 

When passive hyperemia persists for any length of time, a serous 
transudation often occurs through the walls of the capillaries and veins. 
The liquid that is thus poured forth contains less albumin than the 
plasma of the blood, and a few of the corpuscles of the blood are some- 
times visible. The transudation accumulates in the interstices of the 
tissues, where it constitutes oedema; when the serous cavities of the 
body are thus occupied it is termed dropsy. Sometimes a tendency to 
hemorrhage is coincident with the process of transudation. Such 
effusions are not dependent upon mere stagnation of the blood ; the 
vascular wall is in an unhealthy state, and its innervation is also defec- 
tive. Under such circumstances, passive hyperemia and a general 
cachexia are favorable to the process of transudation. The retention 
of the effusion in the interstices of the tissues and in the serous cavities 
is due to a morbid condition of the lymphatic channels through which 
surplus liquids should be normally returned to the general circulation. 
Thus may be explained the oedema and dropsy that accompany chronic 
nephritis, scurvy, tuberculosis, cancer, etc. 

Leaving out of consideration those hemorrhages that are occasioned 
by violence, and by alterations in the atmospheric pressure, such as are 
observed during balloon ascensions or upon the summits of high 
mountains, it should be noted that hemorrhage is frequently caused by 
an increase of intra-vascular pressure. It is in this way that subcuta- 
neous hemorrhage is produced during an epileptic convulsion ; and 
active hyperemia from any cause is often accompanied by a vascular 
rupture. Such lesions of the vascular walls are especially liable to 
occur when the vessels are in a condition of disease ; atheroma, endarter- 
itis, peri-arteritis, and miliary aneurisms are frequent causes of such an 
accident. Obstacles in the course of the circulation often occasion 
hemorrhage through changes in the nutrition of the vascular walls that 



46 PRELIMINARY CONSIDERATIONS. 

are dependent upon stagnation of the blood. For this reason the 
formation of an infarct in any organ of the body is usually accompanied 
by hemorrhage. Considerable alterations in the quality of the blood 
through infective processes frequently occasion such change in the 
nutrition of the vascular walls that hemorrhage occurs. This may be 
witnessed in the hemorrhagic forms of the infective diseases— scurvy, 
purpura, snake poisoning, and occasionally after the administration of 
iodide of potassium. It is also probable that hemorrhage may some- 
times occur as a consequence of violent disturbance of the nervous 
system, and that the visceral hemorrhages which have been observed in 
connection with certain lesions of the brain are thus explained. 

Local anaemia in an organ or tissue may be simply the local conse- 
quence of general anaemia ; but under such conditions the consequences 
are less formidable than when local anaemia is produced by mechanical 
causes, such as the occlusion of a vessel by thrombus or by embolism. 
Sometimes very serious disturbances are produced by transient functional 
anaemia, such as may be witnessed when the brain is rendered tempo- 
rarily anaemic in syncope. In certain morbid conditions of the nervous 
system transient local anaemia may be observed in the extremities, or 
elsewhere, as a consequence of spasmodic occlusion of the arteries that 
lead to the affected part ; such phenomena are not uncommon in hys- 
teria. If a similar occlusion, by reason of atheroma, embolism, or 
other permanent obstruction, should be produced, a visceral infarct, or 
complete gangrene, would occur, according to the location of the 
obstruction. 

The term thrombosis signifies the more or less complete obstruction 
of a bloodvessel by intra-vascular coagulation of the blood during the 
lifetime of the patient. Such clots are formed as a consequence of 
alterations in the vascular wall, accompanied by destruction of the 
endothelium ; or they may be produced by the lodgment of an embolus ; 
or by changes in the quality of the blood. Stagnation of the blood is 
also favorable to the formation of a thrombus. Such clots are therefore 
not uncommon in cardiac and arterial diseases, and in cachectic condi- 
tions of the body. Embolic obstruction of the circulation is caused by 
the entrance of solid bodies of every kind into the channels of circula- 
tion. Such bodies are usually detached from previously existing 
thrombi within the bloodvessels, or they may be loosened from the 
vegetations that form upon the inflamed valves of the heart in endocard- 
itis. Sometimes cancerous or tuberculous masses find their way into 
the bloodvessels. The capillaries of the lungs or of the brain are 
sometimes obstructed by globules of oil that are derived from the 
marrow of bones that have been fractured by violence. In like manner 
the floating fragments of a bacterial colony are not unfrequently 
arrested in the capillary vessels to which they have been transported 
from the original centre of infection, thus producing an extensive diffu- 
sion of infective disease. In this way the dissemination of miliary 
tubercles, the formation of pyaemic abscesses, and other similar facts, 
may be explained. 

In the majority of cases the formation of a thrombus is followed by 
its organization. The endothelial cells of the vascular wall proliferate 



DISORDERS FROM DISTURBANCES OF CIRCULATION. 47 

and penetrate its substance, which also becomes permeated by capillary 
bloodvessels that apparently proceed from the nutrient capillaries of 
the vascular wall itself. In this way a low form of organization is 
effected, and the adjacent walls of the bloodvessel become thickened 
and condensed. The occluded vessel is finally transformed into an 
impervious, cord-like mass of connective tissue. A collateral circula- 
tion is established through neighboring vessels, or through the dilatation 
of the nutrient vessels in the vascular wall. Sometimes the thrombus 
retracts sufficiently to permit the return of blood to its original channel ; 
or the newly organized mass may become hollowed out in such a way 
as to give passage for the blood through a series of communicating 
cavities in the thrombus itself. 

Dropsy. The interstices of the tissues and the serous cavities of the 
body contain in health a certain amount of fluid by which the internal 
surfaces of the body are kept moist, and nutriment is furnished to the 
cellular elements of the tissues. If the amount of this fluid exceeds the 
quantity ordinarily needed for these purposes, it constitutes oedema 
when accumulated in the interstitial spaces, or dropsy when distending 
the serous cavities. Such morbid effusions closely resemble in consti- 
tution the blood serum, and contain very few of the cellular elements of 
the blood or of the constituents of fibrin. The principal causes of 
such transudation are arterial dilatation accompanied by deficient inner- 
vation of the part ; obstruction in the outlets of the veins or of the 
lymph channels ; alterations in the walls of the capillary vessels ; insuf- 
ficient elasticity of the tissues ; and an abnormal composition of the 
blood. 

When dropsy tends to become generalized it is called anasarca; 
when the transudation is localized, as in the areolar tissues of the eye- 
lids or scrotum, it is called oedema. 

The following definitions will be found of service in the study of local 
dropsies : 

Hydrocephalus : Dropsy of the ventricles of the brain. 

Meningocele : A protrusion of the membranes of the brain through 
a congenital opening in the skull. 

Hydrorachis : Dropsical accumulation within the central canal of the 
spinal cord. 

Hydrophthalmus : Dropsy of the eyeball. 

Hydrothorax : Dropsy of the pleural cavity, 

Hydropericardium : Dropsy of the pericardium. 

Hydroperitoneum or ascites : Dropsy of the peritoneal cavity. 

Hydronephrosis : Dropsy of the pelvis of the kidney and ureter. 

Hydrometra : Dropsy of the uterus. 

Hydrosalpinx : Dropsy of the Fallopian tube. 

Hydrarthrosis: Dropsy of the joints. 



48 PRELIMINARY CONSIDERATIONS. 

CHAPTER VII. 

CONTAGION AND INFECTIVE DISEASES. 

It has been known from time immemorial that certain diseases are 
produced by the transmission of matter of some sort from a diseased 
person to a healthy individual. Various skin diseases are thus propa- 
gated. Witness the common form of scabies that is spread by the 
migration of the itch mite from person to person. Intestinal worms 
may be transmitted from one animal to another; and various protozoa, 
such as the amoeba of dysentery and of tropical diarrhoea, or the Plas- 
modium malariae, may in like manner excite disease in the human 
organism. A considerable number of diseases, therefore, are de- 
pendent upon parasitic causes. It will be shown that the phe- 
nomena of inflammation may be caused by chemical products yielded 
by certain microscopical vegetable parasites known as the pyogenic 
cocci. With the progress of investigation it has been discovered that 
certain other diseases are produced by the entrance and activity of 
other minute vegetable parasites which invade the tissues and disorder 
the functions of the organism, thus producing what are termed infective 
diseases. 

A large amount of time and ingenuity was formerly expended in the 
attempt to establish a distinction between the terms contagion and 
infection, but it is now recognized that there is no essential difference 
between a contagious process and an infective process. A disease was 
said to be contagious when, like syphilis or scabies, it was caused by 
direct contact with the bearer of disease ; it was said to be infective, 
when, like typhoid fever, malarial fever, or influenza, it was contracted 
through the medium of the air that was breathed or the water that had 
been drunk by the patient. Certain diseases, like malarial fever, were 
said to be of miasmatic origin : the term miasm being employed to 
indicate any volatile poison that might in some way arise from the earth 
into the air. But in all such cases it is now recognized that something 
has entered the body of the patient, and that the disease with which he 
suffers is nothing more or less than the disorder of function that is 
caused by such invasion. The invasive agent is in general terms desig- 
nated a contagium or contagion. 

The physical characteristics of a contagium may be exceedingly 
various. It may be an egg, like the ovum of a tapeworm ; it may be 
a microscopical fungus, scarcely visible with the highest powers of the 
microscope ; it may be a solid substance, like the scab from the pus- 
tule of smallpox ; it may be a liquid, like the lymph or pus from a 
chancre ; or it may be a volatile substance, like the contagia of influenza, 
or of dengue. It may be capable of remaining inert in the dust of 
the earth, like the bacillus of tetanus ; it may be miscible with water, 
like the typhoid bacillus ; or it may rise with watery vapor into the 
atmosphere, like the protozoon of malaria. 



CONTAGION AND INFECTIVE DISEASES. 49 

A contagion may operate upon the external surfaces of the body, 
a ~iong the epithelial cells of the skin, after the manner of the itch 
rrite, or the microphytic causes of other cutaneous diseases. It may 
enter the current of the blood through the respiratory organs, like the 
tubercle bacillus ; it may penetrate the walls of the alimentary canal, 
like the trichina spiralis, or the typhoid bacillus; and it may find 
access to the circulating fluids of the body through wounds or abra- 
sions upon any of its surfaces. 

Parasitic contagia which thus attack the cutaneous surfaces of the 
body, when of animal character, are termed epizoa ; when they belong 
to the vegetable kingdom they are termed epiphytes. Animal and 
vegetable parasites that invade the tissues and cavities of the body are 
termed respectively entozoa and entophytes. 

It has been shown by careful investigation that the majority of con- 
tagions consist either of minute parasitic plants, called microphytes, or 
of soluble chemical substances that are secreted by them. These 
microphytes bear to their corresponding diseases a relation very similar 
to that which exists between the pyogenic microphytes and the process 
of inflammation. This relation has been completely demonstrated in so 
large a number of the infective diseases that it is impossible to exclude 
the inference that all diseases of an infective character are thus pro- 
duced. The minute vegetable organisms to which the virulence of the 
different contagia is due belong to the fungi, a class of plants of which 
the yeast plant, the mould that occurs upon stale bread, and the ordi- 
nary mushroom, are conspicuous members. These plants are destitute 
of chlorophyl, consequently they are unable, like the more highly 
organized plants, to derive nourishment from carbonic acid gas and 
other inorganic compounds that contain carbon. They obtain their 
food from substances of an organic character in which carbon has been 
already combined with other elements, and has become a constituent of 
the living tissues of a plant or an animal. When the fungus feeds upon 
dead organic matter derived from plants or animals, it is called a sapro- 
phyte; such are the moulds and mushrooms that occur upon the trunks 
of dead trees. If the fungus vegetates in or upon the tissues of a 
living plant or animal, it is termed a parasite. Of these the most 
familiar examples are the microphytes by which infective diseases are 
excited. 

Among the parasitic fungi are other sub-classes in which are included 
the microphytes that are capable of exciting disease in the body of an 
animal. 

1. The moulds are the most conspicuous and highly organized of 
these three classes. A piece of mouldy bread perfectly exhibits their 
mode of growth and structure. With a magnifying glass of low power 
it is very easy to observe their growth and their rudimentary inflores- 
cence — anticipating, as it does, the far more elaborate floral organs of 
the higher plants (Fig. 29). Among these moulds are found the para- 
sitic plants that cause ringworm, pityriasis, and herpes tonsurans. 

2. The second class of pathogenic fungi is represented by the para- 
site that grows in the mouths of unhealthy infants, where it produces a 
disease called thrush. This fungus is usually described as a species of 

4 



50 



PRELIMINARY CONSIDER ATIOXS . 



the genus saccharomyces, of which the ordinary yeast plant is probably 
the best known species (Fig. 30). The members of these two classes 
are saprophytes, i. e., they derive their nourishment from dead or dying 
tissues. Accordingly they cannot flourish upon a healthy cutaneous 
or mucous surface. They invade the skin or the mucous membrane 
only after it has become degraded through imperfect hygienic condi- 
tions from the normal standard of health. 



Fig. 29. 



Fig. 30. 




Mucor corymbifer. a. Aerial processes. 
b. Mycelium vegetating beneath the sur- 
face of the gelatin. c. Fruit stalks. 
d. Sporangia. X 100. (Ziegler.) 




Yeast fungus. X 500. (Bristowe.) 



3. The majority of the pathogenic microphytes constitute the sub- 
class of fungi known as bacteria. These are minute unicellular 
organisms which consist of a usually colorless protoplasm, surrounded 
by a delicate membrane that corresponds to the wall of an ordinary 



Fig. 3 








Bacilli anthracis. X 500. a. Rods. b. Filaments in different stages obtained by 
cultivation, c. Spores. (Bristowe.) 

cell. Sometimes minute granules and apparently empty spaces are 
visible in the protoplasmic contents of the organism ; and under cer- 
tain conditions of nutrition they are capable of producing spores, which 
are analogous to the seeds of higher plants (Fig. 31) ; but under other 



CONTAGION AND INFECTIVE DISEASES. f)l 

conditions propagation is effected by the division of each structure into 
two or more perfectly organized bodies that possess all the characteris- 
tics of the parent cell. 

These bacterial organisms are frequently surrounded by a gelatinous 
envelope, and they are also sometimes provided with delicate hair-like 
processes, or flagella, by the aid of which the microphyte is capable of 
moving itself. This is especially true of the rod-like bacilli, many of 
which are capable of very rapid movement. 

Bacteria may exist in a state of isolation, but those species which 
are provided with a gelatinous envelope usually grow in colonies of 
considerable size, forming clusters like the spawn of a frog. Such 
groups of bacteria are termed zooglea. 

The species of bacteria are very numerous, but they may be grouped, 
morphologically, into three sub-genera: 1. Micrococcus; 2. Bacillus ; 
3. Spirillum. It has been ascertained that with certain exceptions 
these forms are interchangeable, so that by varying the constitution of 
the nutrient medium in which the microphyte is developed, it may be 
made to assume the form of a micrococcus, of a bacillus, or of a spiril- 
lum. Mere form alone, therefore, does not suffice to distinguish differ- 
ent bacteria from one another ; it is necessary to study their mode of 
growth under various conditions, and their pathogenic properties when 
introduced into an animal body. The following are the principal 
characteristics of the infective bacteria : 

1. The members of the sub-genus micrococcus are minute spherical 
bodies, of which the length of the largest seldom exceeds one-seventh 
of the diameter of a red blood-corpuscle. They may be distinguished 
from minute particles of albumin or of fat by their resistance to the 
action of dilute acids, alkalies, alcohol, and ether. They are colored 
by aniline-violet, and do not readily part with the dye under the influ- 
ence of decolorizing agents. 

Fig. 32. 






?~ 



m 



Diplococcus pneumoniae. (Ham.opkau). 
Fig. 33. Fig. 34. 



38l 



Oft n /? f* -P 00^°0^i^0°o' O < ^ ~ 



/ 



Streptococcus. Staphylococcus. 

(Hallopeau.) 



The manner in which micrococci are aggregated exhibits consider- 
able variety (Fig. 32). When united in pairs they are called diplo- 
cocci ; when arranged in the form of a chain (Fig. 33) they are called 
streptococci ; when grouped in a cluster (Fig. 34) they are known as 
staphylococci. Sometimes they are grouped by fours or by multiples 



52 



PRELIMINARY CONSIDER ATIOXS . 



of four, of which the (Fig. 35) sarcina, sometimes found in the 
fluids of the stomach, and the tetrageni (Fig. 36) that vegetate in the 
pus of pulmonary cavities, afford examples. 



Fig. 35. 




Fig. 36. 



2*. N fc *«■-«?• 



Sarcina ventriculi. X 400. (Zieglbr.) Micrococci grouped in cubes (merismopedia) 

from a softening infarct in the lungs. X 500. 
(Ziegleb.) 

2. The bacilli are slender rod-like structures of variable proportions 
(Fig. 37) : some of them are exceedingly short and thick, while others 
are very long and slender. 

3. The spirilla or spiro-bacteria exist either in the form of short 
curved rods, or they may develop to considerable length, characterized 
by a spiral or corkscrew shape. (Fig. 38.) 



Fig. 37. 



Fig. 38. 





Bacilli of leprosy. (Neisser.) 



v K 



\ 



Spirilla of relapsing fever. 
(Brtstowe.) 



500. 



Pathogenic bacteria that originate and are propagated outside of the 
body are called eetogenous bacteria ; such are the contagious micro- 
phytes of pyaemia, of typhoid fever, and of cholera. When they grow 
and multiply only in a living organism, they are termed endogenous, 
e. g., the bacilli of tuberculosis and of leprosy. In the case of cholera, 
and of some other infective bacteria, the contagion cannot be trans- 
mitted directly from one person to another, but it must undergo a cer- 
tain form of elaboration outside of the body before it can act again as a 
virulent agent. 

Like other plants, many of the bacteria can exist only in certain 
countries. Thus cholera does not become domesticated outside of 
India, and the yellow fever prevails continually only around the Gulf of 
Mexico. Diseases that are thus permanently located in a given terri- 
tory are termed endemic diseases; while diseases that are observed 
only occasionally, as a consequence of importation and temporary inci- 
dence, if they prevail extensively in a community, are termed epidemic 
diseases. Thus yellow fever is endemic in Havana, but epidemic in 



CONTAGION AND INFECTIVE DISEASES. 53 

New Orleans or Memphis. An endemic disease that prevails moder- 
ately, may, under certain conditions, acquire great power of extension, 
exhibiting the features of an epidemic, e. g. y cholera, always prevailing 
endemically along the banks of the lower Ganges, may become epidemic 
and spread throughout the entire population of vast districts in the 
peninsula of India. When an epidemic disease thus attacks a large 
proportion of the inhabitants of a country, it is said to be pandemic. 

The causes of these differences in the behavior of disease-producing 
bacteria are numerous and complicated. In the first place their growth 
is largely dependent upon the temperature of the air and of the water. 
Yellow fever prevails only in warm climates, or during the warm 
season of the year within the temperate zone. The tubercle bacillus mul- 
tiples only at the temperature of the human body. The majority of 
bacteria preserve their vitality below the freezing-point of water. 
Typhoid bacilli may live for months inclosed in a cake of ice. On the 
contrary, an elevated temperature is quickly fatal to their existence, 
though the spores of certain bacilli may endure a temperature above 
that of boiling water for a number of minutes. Though it is true that 
certain infective diseases, like dysentery and typhus fever, sometimes 
rage with great severity during the winter months, it is largely due to 
the fact that cold weather causes the accumulation of filth and foul air in 
the unventilated habitations of the poor, thus favoring the development 
of disease. As a general rule it may be asserted that warmth and 
moisture favor the growth of bacteria precisely as they favor the 
growth of more highly organized plants. 

It is a matter of observation that the growth and multiplication of 
bacteria is largely dependent upon the chemical characteristics of the 
soil and water in which they are placed. Slight differences in these 
particulars determine their multiplication or their destruction. It is 
for this reason, undoubtedly, that yellow fever is endemic only in the 
Gulf of Mexico, and cholera only along the borders of the Ganges and 
other Indian rivers. In like manner, the possibility of bacterial infec- 
tion of the human body is in great measure determined by the condi- 
tion of the tissues that furnish the soil in which these microphytes 
must vegetate. Careful laboratory experiments have shown how 
dependent is bacterial growth upon the presence or absence of certain 
mineral constituents in the substances that serve as media for their 
culture and growth. The presence or absence of acids and alkalies is 
a matter of great importance, since bacteria cannot grow in an acid 
medium, though moulds may flourish in the presence of a dilute acid. 
The mould aspergillus niger requires not less than a dozen chemical sub- 
stances for its complete fertilization. If deprived of any one of them, the 
luxuriance of the vegetation is greatly diminished. An almost infini- 
tesimal quantity of nitrate of silver or of corrosive sublimate suffices to 
destroy the life of a microphyte — an excellent illustration of the 
powerful germicidal properties of these salts. 

The growth of bacteria is greatly influenced by the presence or 
absence of free oxygen. Certain bacteria require an abundance of 
oxygen, while others flourish best in an atmosphere or medium that 
does not contain the gas. Microphytes that require oxygen are called 



54 PRELIMINARY CONSIDERATIONS. 

aerobic; those which flourish without oxygen are termed anaerobic. 
The infective parasites that flourish in animal tissues are anaerobic. 
It has been observed that when the yeast fungus is furnished with an 
abundant supply of oxygen it grows luxuriantly, but yields less alcohol 
than when the supply of oxygen is greatly restricted. In like manner 
the poisonous secretions of other microphytes exhibit different degrees 
of virulence according to the amount of oxygen with which they are 
supplied. 

It thus becomes possible to understand why infective diseases do not 
prevail alike in all countries and at all seasons of the year, and why 
certain individuals are susceptible to an infective disease, like cholera, 
typhoid fever, or tuberculosis, while others, who live perhaps in the 
same family, escape with perfect immunity. It also explains why 
certain infective diseases attack certain animals, while other species 
escape ; thus anthrax prevails among sheep, cattle, rabbits, and human 
beings, but does not attack the horse or the dog ; syphilis prevails 
among human beings, but is unknown among the lower animals ; 
typhoid fever invades the human species, but can be only with great 
difficulty inoculated upon any of the lower animals. These differences 
in the susceptibility of the tissues of different animals and of different 
individuals constitute what is termed receptivity. The differing degrees 
of receptivity that are observed are undoubtedly due to minute differ- 
ences in the chemical composition of the liquids and solids of each 
individual body. It is to the departure from the normal composition 
and constitution of the tissues, producing what is known as scrofula, 
that must be referred that heightened receptivity for the tubercle 
bacillus which characterizes the victims of tuberculosis; and it is to the 
different composition of the tissues and liquids of the body at different 
ages, and under varying conditions of life, that corresponding variation 
in susceptibility to disease must be ascribed. 

Considerations of this character render it possible to understand 
how the receptivity of the individual may be heightened by the opera- 
tion of causes that interfere with the normal functions of the tissues. 
Thus excessive heat or cold, hunger or thirst, fatigue or the occurrence 
of trifling maladies, may temporarily modify the processes of nutrition, 
assimilation, secretion, and excretion, so that the fluids of the body 
undergo an appreciable change in their composition, which may favor 
the invasion of a parasitic contagion. The recent occurrence of one 
infective disease may thus favor the attack of another, as may be 
frequently witnessed when tuberculosis promptly follows a course of 
measles or of typhoid fever. 

On the other hand, the receptivity of an individual may be dimin- 
ished by the operation of causes that favor the healthy nutrition of 
the tissues. In the case of many infective diseases receptivity is 
diminished by their occurrence. Thus measles, scarlet fever, typhoid 
fever, smallpox, and varicella, leave the body in a condition of dimin- 
ished or utterly extinguished receptivity for their contagion. This 
diminution of receptivity extends also to the offspring of such patients. 
Thus smallpox, scarlet fever, measles, yellow fever, and other infective 
diseases, are least fatal among the descendants of a people among 



CONTAGION AND INFECTIVE DISEASES. 55 

whom those diseases regularly prevail. The immunity that is thus 
displayed by certain individuals under certain conditions, has been 
shown to be due to the quality of the serum of the blood and other 
liquids in the tissues of the body. These liquids contain albuminous 
compounds which are destructive to the vitality of bacteria. In certain 
animals the immunity against particular infective bacteria is complete 
so long as their liquids contain a sufficient quantity of the antidote to 
bacterial growth ; and by injecting into the circulation of an animal 
that is receptive to certain contagia the serum from the blood of an 
animal that possesses immunity against such infection, the susceptible 
animal may acquire immunity, and may escape the consequences of an 
inoculation that would have been otherwise fatal. Thus if the serum 
of a white rat, which is insusceptible to anthrax poison, be injected 
into white mice, which are naturally very susceptible to anthrax, they 
will acquire perfect immunity, and can be inoculated with anthrax 
poison without any unfavorable results. 

Before proceeding further in the study of immunity, it is necessary 
to recall the manner in which bacterial poisons invade the body and 
disorder its functions. It has been already remarked that these micro- 
phytes grow and multiply like other plants. Their multiplication is 
usually effected by a process of simple division, which proceeds with 
such rapidity that under favorable conditions they may double their 
number every twenty minutes. At this rate they may increase in 
number many thousand-fold in the course of a few hours. Another 
mode of propagation consists in the formation of spores within the 
protoplasm of the minute organism ; these, under favorable circum- 
stances of warmth and moisture, are developed into microphytes like 
those from which they were produced. These spores possess great 
vitality, and are not disorganized at ordinary temperatures. They 
may be exposed for many hours to a dry heat considerably above that 
of boiling water without destruction. 

The rapid rate of multiplication that characterizes certain bacteria 
renders it possible for them to interfere with the functions of animal 
tissues by their overwhelming presence, thus producing mechanical 
obstruction in the bloodvessels and lymphatic channels of the body. 
In anthrax and some other diseases, capillary embolisms, renal infarcts, 
and mechanical injuries of the vascular walls may be thus explained. 
These obstructions, however, do not occur in the majority of infective 
diseases, since such excessive proliferation of microorganisms does not 
commonly occur in the tissues. 

Like other plants, bacteria require nourishment. This they procure 
from the liquids in which they grow, and by such abstraction of nutri- 
ment they may considerably interfere with the nutrition of the normal 
tissues. They also secrete certain substances, of the nature of diastase, 
which act upon the neighboring tissues, and modify the alimentary 
principles which they contain, so that they become fitted for bacterial 
food. It is in the laboratory a matter of common observation that 
starch is thus transformed into glucose, while albuminoids are converted 
into peptones, and urea into carbonate of ammonia. Besides these 
familiar examples of the effects of bacterial action, it has been ascer- 



56 PRELIMINARY CONSIDERATIONS. 

tained that they secrete poisonous substances, and transform harmless 
albuminous matter into deadly toxines. The substances that are thus 
produced through the activity of bacteria are quite numerous. Besides 
sulphuretted hydrogen and sulphide of ammonium, certain volatile fatty 
acids and numerous alkaloids are produced that are quite analogous to 
the alkaloids contained in the tissues of more highly organized plants. 
The soluble poisons that are described under the name of ptomaines 
have a similar origin, and their deadly quality has been frequently 
tested. When they find their way into the body of a healthy ani- 
mal they produce dilatation and irregularity of the pupils, disturb- 
ances of the heart, muscular relaxation, convulsions, and death. All 
these products of bacterial growth are well defined chemical com- 
pounds, and the action which they produce upon the tissues of the 
body is a chemical reaction. It is now admitted that the majority of 
the disorders that are produced by the entrance of bacteria into the 
body are due to the formation and diffusion of these chemical poisons. 
It will be shown, in connection with the study of inflammation, 
that the inflammatory process is consequent upon the reaction of 
the tissues under the influence of chemical poisons that are secreted by 
the pyogenic bacteria. An analogous reaction occurs in connection 
with every form of bacterial invasion when the tissues are not abso- 
lutely overwhelmed by an excess of their poisonous secretions. When 
the animal tissues are excited by moderate doses of an infective poison 
they are stimulated to the production of a counter-poison, or anti-toxine, 
as it is frequently called. It is to the presence of such counter-poisons 
or anti-toxines in the blood and liquids of the body that immunity is 
due. Yfhen the anti-toxine is sufficient in quantity and in vigor, 
bacterial invasion cannot occur, for the bacteria are destroyed as fast 
as they enter the body. When this condition exists as an original 
quality of the blood, it constitutes what may be designated as natural 
immunity. It is to the production of such counter-poisons that the 
limitation of bacterial diseases of short duration is probably to be 
ascribed. The infective process is itself the stimulus that excites the 
tissues to the production of the antidote, and so soon as it has been 
produced in sufficient quantity the further proliferation of invasive bac- 
teria ceases ; they perish, and are eliminated from the body. For this 
reason many infective diseases are said to be self-limited. So long as 
the increased production of the counter-poison continues after such an 
experience the body is protected against a return of the disease, through 
the establishment of what may be termed acquired immunity. But if, 
as sometimes happens, the tissues cease to furnish the counter-poison, 
re-infection again becomes possible. In this way may be explained the 
immunity that is acquired through an attack of smallpox, scarlet fever, 
typhoid fever, etc., and also the occasional recurrence of these diseases 
in the same individual. 

Artificial immunity consists in the more or less complete loss of sus- 
ceptibility to a contagion through an artificial infection with the same 
or a similar contagion. Contagious matter, or virus, as it is usually 
termed, when transmitted in the normal way reproduces itself and the 
disease that is dependent upon its action ; but the quality of a virus 



CONTAGION AND INFECTIVE DISEASES. 57 

may be artificially modified before its introduction into the body, or its 
intensity may be diminished by some special method of inoculation, 
so that the violence of its effect is reduced to a degree that admits of 
life and the recovery of health, after which re-inoculation with strong 
virus produces no effect. Immunity may be acquired by repeated 
inoculations with a potent virus, in quantity too small to produce 
violent reaction. By this method the tissues are gradually excited to 
the production of counter-poisons until they finally become tolerant of 
the contagion in any quantity. The mode of introduction also exerts 
a great influence upon the action of a contagion. Thus the conse- 
quences of ordinary infection with smallpox virus are far more severe 
than when the same virus is introduced by inoculation into the skin, 
because the local inflammatory reaction of the tissues apparently reduces 
the intensity of the virus, so that a moderate reaction results without 
general eruption or alarming symptoms. In like manner the conse- 
quences of tubercular infection are more severe when the contagium 
enters the body through the respiratory passages than when it is intro- 
duced through the skin. The consequences of ordinary tubercular or 
syphilitic infection, moreover, are less severe than the results of infec- 
tion through the umbilical vein in foetal syphilis and foetal tuberculosis. 
Similar differences are observed in other infective diseases. 

Certain contagia lose a portion of their virulence by transmission 
through animals of another species. In this way the intensity of the 
virus of smallpox becomes reduced or attenuated by transmission through 
a cow or a horse. The virus of hydrophobia may be in like manner 
attenuated by transmission through a series of monkeys. The virus of 
hog cholera may be attenuated by transmission through a number of 
rabbits, and the weakened virus may be then inoculated into the pig, 
producing in that animal artificial immunity against the effects of the 
original virus from which the modified form was derived. The attenu- 
ated virus of smallpox that is obtained by transmission through the 
calf constitutes the well-known vaccine virus that gives immunity 
against smallpox. 

Virulent contagia become attenuated by age; thus, an old culture of 
anthrax virus is considerably weaker than a freshly prepared specimen. 
Similar modifications are exhibited by the virus of chicken cholera, so 
that by inoculation with a virus that has been thus modified immunity 
is produced. 

Many forms of virus may be attenuated by an elevated temperature. 
By subjecting a contagion to a moderate heat, for a considerable period 
of time, the intensity of the poison is greatly reduced, and its inocula- 
tion affords artificial immunity against active forms of the contagion. 

In like manner the influence of the solar rays and of oxygen, either 
free in the air or acting under pressure, serves to produce attenuation 
of the contagion of anthrax, chicken cholera, and other infective 
agents. 

The process of desiccation is employed for the purpose of attenuating 
the virus of hydrophobia. The spinal cord of an inoculated rabbit is 
suspended in dry air ; its virulence diminishes day by day until it is 
completely extinguished. A series of cords containing virus in a dimin- 



58 PRELIMINARY CONSIDERATION'S. 

ishing ratio may be thus prepared, and by successively inoculating an 
animal with virus prepared from such cords, beginning with that of 
least intensity and advancing to that of greatest virulence, complete 
immunity may be secured. 

A virus maybe attenuated by the addition of antiseptics in quantity 
insufficient for their destruction. In this way the virus of anthrax has 
been transformed into a protective vaccine by the addition of small 
quantities of potassium bichromate, carbolic acid, corrosive sublimate. 
3-naphthol, and other chemical compounds. 

The relation of smallpox virus to ordinary vaccine has been already 
noted. By the French it is denied that vaccine virus is an attenuated 
smallpox contagion, but by many other observers this relationship is 
affirmed upon the basis of the experiments of Ceelev. Badcock. and 
others. There are, however, cases in which the contagion of one infec- 
tive disease operates in some degree to attenuate the contagion of 
another infective disease. It is in this way that the virus of chicken 
cholera is protective against the contagion of anthrax : and probably 
the apparent antagonism between erysipelas and lupus may be thus 
explained. 

The active agent in the production of artificial immunity by the 
methods above described is not the bacterium itself, but is to be sought 
in its secretions. It has been ascertained that inoculation with virus 
from which the infective bacteria have been removed by filtration is 
quite as effective as that which contains the microphytes themselves — 
a fact which indicates that immunity is the result of a chemical action 
upon the tissues. This action is not limited to the mere circulation of 
a virulent liquid in the blood and lymph of the inoculated animal. It 
is a process that is effected within the protoplasm of the lymph-cells of 
the organism, causing a modification of their structure and function 
that results in the production of counter-poisons by which they protect 
themselves against subsequent infection. This process requires con- 
siderable time ; if an animal be inoculated with an attenuated virus, 
and then immediately re-inoculated with the unmitigated form of the 
virus, the ordinary malignant consequences of such an infection are 
exhibited. But if a period of three or four days be interposed between 
the protective inoculation and the subsequent virulent infection, no 
serious consequences are manifested : the tissues have modified their 
functions, and are protected. 

Artificial immunity may be more or less complete according to the 
degree of attenuation of the protective virus. Various circumstances 
tend to modify the results so that, although it is possible in dealing 
with the lower animals whose life is short, to secure an immunity that 
is sufficient for a comparatively brief number of months or years, very 
little is known about the possibility of obtaining such favorable results 
among human beings. In fact, the only example of artificial immunity 
of which the human species has any extensive experience is the immu- 
nity against smallpox that is acquired by vaccination. It is now well 
known that the protective effects of such vaccination are not always 
permanent, and that re-vaccination should be practised every few 
years. 



CONTAGION AND INFECTIVE DISEASES. 59 

Since the study of bacteriology is yet in its infancy, much remains 
to be learned regarding the products of bacterial growth and their mode 
of action. Already it appears that the secretions of these microphytes 
are very complex, and that they contain substances endowed with very 
different characteristics. Some of these are believed to represent the 
poisonous energy of the virus, while others are supposed to act as pro- 
tective antidotes to the first, or as special stimulants to the resistant 
energy of the tissues with which they come in contact. That the 
plasma and the serum of the blood after bacterial infection contain both 
toxines and anti-toxines is certain, but opinions are divided with regard 
to the source of the anti-toxines. In the opinion of some they are the 
products of bacterial secretion, while others — and this seems to be the 
more probable view — believe that they are furnished by the cells of the 
tissues which are stimulated to their secretion under the influence of 
invasive infection. Undoubtedly the chemistry of the future will dis- 
cover methods for the separation of these different prnciples, and for 
the artificial production of antidotes similar to those through which the 
tissues provide themselves with immunity. Already the anti-toxine of 
the poison of tetanus, obtained from the blood of inoculated animals, 
has been successfully used as an antidote to the disease, both in the 
lower animals and in the human subject. 

Passing now from the consideration of the subject of immunity to 
the study of the manner in which bacterial invasion of the organism is 
effected, it appears that when a contagion enters the body of an animal, 
its microphytic agents may be either disseminated throughout the 
organism, or they may remain localized at the point of introduction, 
and may thence diffuse their secretions throughout the entire body. 
The microbes of soft chancre, gangrene, whooping-cough, diphtheria, 
and some other diseases, remain fixed at the site of original infection, 
or extend themselves only to a very limited degree. In malignant 
pustule, glanders, tuberculosis, and erysipelas, the microphytes are at 
first localized, but subsequently become diffused by the transportation 
of infective emboli through the lymphatic channels and bloodvessels. 
The act of vaccination, and the inoculation of the contagion of smallpox, 
consists in the introduction of virus through a puncture in the skin, 
where the infective agent is at first localized, but finally invades the 
entire body and produces general symptoms. The period of local action 
constitutes what is termed the period of incubation. This is variable 
for different infective diseases. The symptoms that are manifested 
when the contagion has become generalized, constitute the characteristics 
of the period of invasion. These symptoms express the reaction of 
the nervous system and the disorders of circulation, secretion, and 
excretion that are produced through the direct action of the invasive 
poison. The consequences of such disturbance constitute the fastigium 
or fully developed stage of the disease ; while the symptoms that 
accompany the disappearance of the contagion and the return of normal 
function in the tissues characterize the period of convalescence. In 
certain diseases the infective contagion apparently passes through suc- 
cessive stages of activity and latency; such diseases are intermittent 
or recurrent in their course ; as, e. g., certain forms of malarial fever 



60 PRELIMINARY CONSIDERATIONS. 

and relapsing fever. In certain diseases, as, for instance, smallpox 
and yellow fever, the symptoms of invasion are followed by a period of 
remission, which again is succeeded by symptoms that indicate a sec- 
ondary or auto-infective process, consequent upon local reactions in the 
skin or internal viscera. 

The limitation of the course of infective disease is accomplished 
through the acquisition of immunity. In certain cases, as in measles, 
scarlet fever, smallpox, etc., this is speedily acquired, and its duration 
is usually permanent. But against other diseases, as, e. </., in diph- 
theria, there is either no immunity, or its duration is exceedingly brief 
and uncertain. In a third class of diseases, such as leprosy and tuber- 
culosis, immunity is rarely, if ever, acquired, and the disease persists 
through life. 

When an infective disease is self-limited and gives place to complete 
recovery, its contagion must be either destroyed or eliminated from the 
body. It is a matter of observation that in such diseases the infective 
bacteria rapidly disappear. They are, perhaps, in some measure 
absorbed and removed by the leucocytes and the cellular elements of 
the spleen and other tissues of the body (phagocytosis). Sometimes, 
as in typhoid fever, they become isolated, and for a time remain encap- 
sulated, as it were, in certain circumscribed localities, whence they 
occasionally issue forth to reinfect the body, producing a relapse of the 
original disease. The final elimination of bacteria is effected through 
the excretory organs, especially through the kidneys, where they may 
be discovered in the glomeruli, in the walls of the uriniferous tubules, 
and in the urine itself. By their presence and by the action of their 
secretions, inflammation of the kidneys is frequently excited. It is for 
this reason that nephritis and retractile albuminuria so frequently 
accompany the course of infective diseases. The skin also shares in 
the eliminative process ; hence, probably the common occurrence of 
eruptive manifestations which are so often witnessed during these dis- 
eases. 

Besides the directly poisonous effects of bacterial invasion, it is im- 
portant to note the consequences of disturbance in the functions of the 
important viscera of the body. Disorder of the kidneys and of the 
liver is especially liable to occur as a consequence either of the direct 
influence of infective microorganisms or their secretions. Such dis- 
orders must necessarily interfere with the efficient excretion of the 
waste products of tissue change. In this way the poisonous products 
of metabolism may be accumulated in the body, giving occasion for 
auto-intoxication of the nervous system and other vital organs. In 
this way delirium, coma, excessive elevation of temperature, cardiac 
failure, and paralysis of the medulla oblongata may be produced, and a 
fatal termination may be reached when otherwise recovery might have 
occurred. It is through analogous processes of auto-intoxication that 
the secondary effects of scarlatina, diphtheria, and influenza are 
evolved. 

A process of secondary infection not unfrequently follows the course 
of a primary infective disease. The pyogenic cocci, which are always 
present upon the surfaces of the body, find its tissues less resistant 



INFLAMMATION. 61 

under the influence of the primary infection ; and the consequences of 
their activity become apparent in the various forms of suppuration that 
occur during the later stages of the original disease. In this way may 
be explained the cutaneous abscesses and the glandular suppurations 
that follow typhoid fever, scarlet fever, and other infective diseases. In 
the same way is originated the form of pneumonia that frequently com- 
plicates influenza, typhoid fever, etc. 



CHAPTER VIII. 

INFLAMMATION. 

It is difficult to present a brief and comprehensive definition of the 
term inflammation, since the process occurs under such various con- 
ditions, proceeds with such variable activity, and arrives at so many 
different results. It has been defined as the reaction of the tissues to 
injuries that are insufficient to produce their paralysis or total destruc- 
tion. It is intimately connected with the capillary circulation, and is 
accompanied by extensive disturbance, not only of the movement of 
the liquids of the body, but of the universal processes of innervation 
and nutrition of the entire organism. The process is usually initiated 
by the entrance of certain species of bacteria into the tissues that are 
about to become the seat of inflammation. Of these bacteria the staphy- 
lococci, streptococci, and pneumococci are probably the most frequent 
exciters of inflammation. Present in the air and upon the surfaces 
of the body, if they find access to tissues that have been weakened by 
injury, they proliferate in the fluids of the part. As they grow they 
secrete poisons that act upon the adjacent cells, producing necrosis or 
atrophy of the cells among which they multiply. Around the parasitic 
colonies thus established are accumulated the leucocytes of the blood 
that have migrated through the walls of the capillaries, forming what is 
termed pus ; while still further away from the necrotic centre is formed 
a zone in which there is active exudation of the plasmatic contents of 
the capillary vessels, and multiplication of the cellular constituents of 
the inflamed tissue. In this way is formed an abscess, in which the 
original bacterial colony constitutes the focus, while the necrotic centre 
becomes surrounded and infiltrated with pus corpuscles, beyond which 
the tissues are condensed by exudation and infiltration. 

The process of suppuration may be also excited by other agents 
besides the poisonous secretions of bacteria. If mercury, or other irri- 
tants that have been thoroughly sterilized, be introduced subcutaneously 
into the tissues in such a way that bacterial infection cannot at the 
same time occur, suppuration follows as a consequence of the irritation 
that is thus excited. Each minute globule of mercury becomes sur- 
rounded by pus corpuscles. It, therefore, is apparent that the exciting 
agent is of a chemical character, and that it is through the chemical 



62 PRELIMINARY CONSIDERATIONS, 

activity of bacterial secretions that the inflammatory process is set up 
after injury and bacterial infection. It is also worthy of note that 
when the products of bacterial secretion are alone injected into the 
tissues, inflammation is often excited, just as if the bacteria themselves 
had been introduced into the organism. Another interesting feature 
that illustrates the infective character of the process by which inflam- 
mation is excited, as well as the intimate relation which it sustains to 
the infective process by which contagious diseases are produced, is fur- 
nished by the observation that under certain circumstances inoculation 
with bacterial virus will produce inflammation, as in vaccination or 
inoculation for smallpox ; while under other conditions local reaction 
does not take place, and the entire organism succumbs to the general- 
ized influence of the poison, as when smallpox is taken in the usual 
way. It follows, therefore, that a poison which, in excessive quantity, 
produces universal death of all the tissues and organs of the body, may, 
in moderate quantities, excite only a local reaction of an inflammatory 
character. 

It has been also observed that the occurrence of local inflammation 
about the point of infection sometimes suffices to protect the organism 
against universal infection, as is observed in certain cases of local 
tuberculosis. The inflammatory reaction may be, therefore, in some 
degree protective against the general diffusion of contagious matter. 
But too often the contagion has been universally disseminated before 
its diffusion can be arrested by an inflammatory reaction, because the 
normal liquids and elements of the body are incapable of neutralizing 
its energy. Under such circumstances general infection takes place, 
either in the form of universal toxaemia, as in diphtheria ; spreading 
inflammation, as in erysipelas ; or multiple abscesses, as in pyaemia. 
When the reaction of the tissues is sufficient to limit the action of the 
pyogenic bacteria, the resulting inflammation is said to be circumscribed. 
But when the virulence of the poison is too great the resistance of the 
normal tissues and liquids is overwhelmed; the inflammatory process 
is then generalized, and is termed diffuse, as in erysipelas. 

Inflammation may be, therefore, defined as the result of chemical 
action upon the elementary parts of a tissue, through which its inter- 
stices become infiltrated with the constituents of the blood, and with 
newly formed embryonic cells. In this way are produced local swelling 
from infiltration, change of color from afflux of blood, pain from com- 
pression and excitement of the nerves, heat and febrile disturbance of 
the organism from disorder of the regulative mechanisms in the nervous 
system. Suspension of function is frequently followed by the death 
and disintegration of the affected tissues, which are subsequently either 
isolated or extruded from the surviving portions of the body. 

The course of the inflammatory process can.be easily observed in 
the tongue of a frog, or in the tail of a tadpole, or in any other living 
translucent membrane. When such a tissue is placed under the micro- 
scope the blood may be seen moving through the vessels of the part, 
the colored corpuscles occupying the axis of the current, while the 
colorless corpuscles and the haematoblasts move less rapidly in the 
peripheral portions of the stream, in contact with the walls of the capil- 



INFLAMMATION 



63 



Fig. 39. 




Migration of white corpuscles. 

X 250. (ElNDFLEISCH.) 



lary vessels. When an irritant, like nitrate of silver, is applied to such 
a membrane, its capillaries can be seen to dilate for a brief period of 
time, during which the flow of their contents is accelerated. After a 
few minutes the blood stream begins to move more slowly, until finally 
it may be completely arrested. During this retardation of the current 
the colorless corpuscles become adherent to the capillary wall, and pres- 
ently begin to pass through the vascular 
membrane into the interstices outside of 
the capillary channels. (Fig. 39.) This 
extravasation of leucocytes is due to a local 
action upon the cement substance in the 
capillary wall by the bacterial secretions 
that excite inflammation. There also ap- 
pears to be exerted a certain chemical 
attraction by which the leucocytes are im- 
pelled toward the source of infection. In 
severe inflammation the colored corpuscles 
are also extravasated in a similar manner. 
This passage of the corpuscular elements 
of the blood through the capillary wall is called diapedesis. Attracted 
toward the central focus, the white corpuscles rapidly accumulate, 
become permeated and swelled by the liquids of the part, and are 
invaded by the bacteria themselves (phagocytosis). If not thus para- 
lyzed or rendered stationary by overcrowding, they may find their way 
into the neighboring lymphatic channels, and thus serve as vehicles for 
the transportation of infective matter to other parts of the body (embolic 
infection). 

Beside the passage of blood corpuscles into the tissues a certain 
amount of liquid from the plasma of the blood finds its way through 
the capillary walls. This contains a larger amount of albumin than is 
found in the transudation of dropsy, though less than is contained in 
the plasma within the vessels. The liquid appears to be forced out of 
the vascular channels by the pressure that is transmitted from the heart 
to the weakened capillary walls, whose endothelial layer acts as a filter, 
permitting the passage of certain constituents of the blood, while others 
are retained. 

The cause of the stagnation of the blood corpuscles and of their 
adhesion to the capillary walls is probably connected with chemical 
changes that affect the specific gravity of the elements of the blood. 
The fluid that has escaped from the bloodvessels, is termed an exuda- 
tion. It contains the elements of fibrin, and therefore undergoes coagu- 
lation. When this occurs upon a free surface, the white corpuscles and 
embryonic cells become entangled in the meshes of the fibrin, and a false 
membrane is thus formed. Examples of this process may be observed 
upon the mucous membrane of the respiratory passages, or upon the 
pleural surfaces within the thorax, or upon the serous lining of the cavi- 
ties in and around the heart. (Fig. 40.) In certain cases such false 
membranes can be stripped off, leaving almost intact the surfaces upon 
which they were formed. In other instances the false membrane seems 
to be partially incorporated with the external layers of the surface upon 



64 



PRELIMINARY CONSIDERATIONS, 



which it is formed, so that separation cannot be effected without lacera- 
tion of the structure. 

When inflammation involves a free surface like that of the perito- 
neum, the endothelial cells that form its smooth external layer become 
loosened and partially detached, while the deeper layers break up and 
assume an embryonic character. (Fig. 41.) The nuclei of the cells 
multiply by division, and thus produce new cells which are added to 
the products of exudation. The same multiplication of embryonic cells 




Fibrinous exudation, a. From diphtheritic 
membrane. X 250. b. From inflamed pleura. 
X 500. (Bristowe.) 



Inflammation of mesentery. X 250. 
(Cobxil and Raxtier.) 



takes place wherever inflammation attacks the deeper tissues of the body. 
(Fig. 42.) In this way, by exudation, and by multiplication of the ele- 
mentary parts, the inflamed structure becomes swelled and consolidated. 
The heat of an inflamed tissue is greater than the natural tempera- 
ture of the part, because of the increased oxidation that accompanies 
cellular proliferation and growth. The temperature is also raised by 
the stagnation of the circulation, and the consequent retention of heat 



Fig. 42. 




Inflammation of cartilage. X 250. (Cornil and Ranvikr.; 



which should be diffused by a normal movement of the liquids of the 
body. The general rise of temperature that is observed throughout 
the body and the acceleration of the movement of the heart constitute 
the principal signs of fever, a condition that is dependent upon a dis- 
turbance of the regulative apparatus by which the liberation, distribu- 
tion, and radiation of heat, and the processes of assimilation, secretion, 
and excretion should be normallv controlled. 



INFLAMMATION. 



65 



The inflammatory process is, therefore, an exaggeration of the pro- 
cesses that have been previously described as hypertrophy and hyper- 
plasia. Hypertrophy consists in the enlargement of the normal 
elements of a tissue under the influence of excitement. Hyperplasia 
consists in the proliferation of the constituent cells of a tissue under 
similar circumstances of excitement. Inflammation is all this, and 
something more. It consists not merely in the multiplication and 
swelling of cellular elements within the tissue, but in the infiltration 
of the part with the products of exudation from the capillary vessels. 
The inflammatory process itself may exhibit varying degrees of activity 
and exudation. In all cases there is an accumulation of leucocytes at 
the seat of inflammation, but they may be so generally diffused among 
the other elementary parts of the tissue, and the amount of coagulation 
may be so great that only a general swelling and consolidation of the 
part can be distinguished. But when the inflammatory process reaches 
a high degree of virulence, the movement of leucocytes toward the 
central focus becomes so active, and the coagulative process is so little 
effective that colliquative necrosis takes place ; a considerable cavity is 
formed in the tissues and is occupied by the products of suppuration, 

Fig. 43. 




Pus-cells. X 500. a. Ordinary appearance, b. Showing amoeboid movements, c. After 
addition of acetic acid. d. Undergoing fatty degeneration. (Bristowe.) 



constituting an abscess. The pus that is thus formed is a more or less 
fluid substance that consists largely of the liquefied and degenerated 
plasma that previously occupied the interstices of the inflamed tissue. 
In this fluid float pus corpuscles, which closely resemble the colorless 
blood corpuscles from which many of them have been transformed. 
(Fig. 43.) They are often larger than the original leucocytes, because 
swelled by imbibition. They are often mixed with other cell structures 
that have been discharged from the neighboring tissues into the puru- 
lent fluid. These elements are no longer capable of organization, but 
are in a state of degeneration and disintegration. 

When pus is produced upon the free surface of a mucous membrane 
the process is termed catarrhal suppuration. When pus is accumu- 
lated within a closed cavity, it constitutes an abscess. Pus corpuscles 
are frequently found in exudations within the serous cavities of the 
body, which thus become converted into abscesses. When the pus cor- 
puscles are numerous, the purulent liquid is thick, creamy, and does 
not exhale any disagreeable odor. Such pus is said to be laudable. 
If air containing the germs of putrefaction finds entrance into a pus 
cavity, decomposition of the liquid takes place, and the corpuscles 



66 PRELIMINARY CONSIDERATIONS. 

undergo rapid disintegration, together with the liberation of offensive 
gases. When the serous constituents of pus are predominant, pus loses 
its laudable characteristics, and more or less closely resembles thin, tur- 
bid serum (ichorous pus). Sometimes the liquid is contaminated with 
blood in various stages of decomposition (sanious pus). When mixed with 
mucus upon the surface of the mucous membrane, the exudation is 
said to be muco-purulent in character. If inclosed in a cavity from 
which it cannot escape, the corpuscles may be removed by disintegra- 
tion and absorption of the debris through the lymphatic vessels. It is 
probable that the cells of contiguous living tissues may take some part 
in this process of absorption. Sometimes the serous portion alone is 
thus removed, and the corpuscles become condensed into a caseous 
mass which sometimes may become finallv infiltrated with calcareous 
salts. 

Under certain circumstances, instead of proceeding to suppuration 
the products of inflammation become organized. This process may be 
observed in the inflammation of connective tissue, such as occurs in 
cirrhosis of the liver, where there is great multiplication of the connec- 
tive-tissue cells of the organ, without formation of pus, or immediate 
death of the inflamed structures. But when a solution of continuity 
has occurred, such as may be observed in a flesh wound, the process of 
repair is somewhat different. The reparative process may occur with- 
out inflammation, if the wound be not infected by the pyogenic bac- 
teria. A clean incision, if speedily closed, heals by first intention. 
There is an exudation of plasma upon the surfaces of the wound, giv- 
ing them a glistening appearance. If, now. these surfaces be placed 
in close apposition, they become adherent, and healing takes place by 
immediate union ; new cells sprout from the contiguous surfaces of the 
wound, and fill the intervening space with newly formed tissue elements 
by which the injury is obliterated, and within a day or two union is 
complete. 

But if the apposition of the divided surfaces be delayed for twenty- 
four or thirty hours, the original glossy surface will become transformed 
into a grayish film that consists of lymph corpuscles and leucocytes 
imbedded in a granular, fibrinous plasma. If, now, the opposite sur- 
faces of a wound in such a condition be drawn together, they become 
adherent in the course of two or three days, and their union will be 
completed in two or three weeks. In this case, a preliminary adhesion 
of the opposite surfaces is effected through the medium of the plasmatic 
exudation, into which newly formed connective-tissue cells burrow their 
way from either side, until they form a union across the wound. In 
this way the primitive exudation serves as a supporting framework for 
the newly forming tissue. The capillary vessels also bud forth from 
the adjacent parts, and penetrate into the growing cicatrix. By this 
proliferation of the cellular elements of the tissue, union is effected, 
and a scar is formed. The original plasma breaks up during this pro- 
cess, and is removed by absorption. It should be noticed, in this con- 
nection, that during the healing process, cellular elements always repro- 
duce their like : connective tissues producing new connective tissue, 
and epithelial cells bringing forth the epithelial investment of the scar. 



INFLAMMATION. 67 

If early adhesion be not secured, the surface of an open wound 
begins to granulate, and the cavity heals by granulation. Its surface 
becomes roughened or granular through the protrusion of minute vas- 
cular tufts that are forced outward by the blood pressure. The heal- 
ing process advances from the margin of the wound toward the centre, 
until it is completely covered with newly formed epithelium. During 
this process, a considerable amount of inflammation and suppuration 
takes place, giving rise to the ordinary phenomena of inflammation that 
can be observed upon mucous surfaces. The deeper parts of the 
wound are chiefly occupied by newly formed connective tissue and 
lymph corpuscles. Along the margin of the ulcer into which the origi- 
nal wound is now transformed, the budding epithelial cells gradually 
extend toward the centre, until the whole surface is covered. Unless 
this process of epithelial growth proceeds with due rapidity, the wound 
will remain unhealed, rendering it necessary to resort to the operation 
of skin-grafting, by transplanting portions of healthy skin to different 
points upon the surface of the ulcer, where they become adherent and 
gradually extend their epithelium over the entire surface. 

When two granulating surfaces are placed in close apposition, their 
union occurs in a manner analogous to healing by first intention. The 
granulations serve as a support for the actively growing connective- 
tissue cells, which finally unite across the cavity of the wound, and by 
their pressure cause atrophy and subsequent absorption of the granula- 
tions themselves. 

Many of the chronic inflammations that involve the deeper tissues of 
the body are not attended by suppuration. When the connective tissues 
of an organ are thus invaded by the inflammatory process the paren- 
chymatous structures are subjected to continuous pressure, resulting in 
their atrophy and disappearance. Such chronic interstitial inflamma- 
tion is termed sclerosis. It occurs in the liver, where it causes con- 
traction and induration of the organ in hepatic cirrhosis. A similar 
process often involves the connective tissue of the spinal cord, consti- 
tuting spinal sclerosis. 

But in certain cases, the parenchymatous structure of an organ is 
the principal theatre of the inflammatory process, constituting what is 
termed 'parenchymatous inflammation. The tissue cells become infil- 
trated and enlarged ; their function is seriously impaired, and they are 
liable to undergo fatty degeneration and destruction. During the early 
stages of both interstitial and parenchymatous inflammation the affected 
tissues are tumefied, causing enlargement of the inflamed organs ; but 
in the later stages of the inflammatory process, contraction, compres- 
sion, atrophy, and degeneration combine to diminish the bulk of the 
inflamed tissue. 



68 



PRELIMINARY CONSIDERATIONS. 



CHAPTEK IX. 



FEVER. 



Fever is a disordered state of the bodily functions, of which the 
most prominent symptom is a protracted elevation of temperature above 
the normal standard. The normal temperature of the body oscillates 
a little above 98.4° F., being slightly lower in the morning, and mod- 
erately increased during the early part of the night ; the normal differ- 
ence between the extremes of morning and evening temperature being 
about 1.5° F. 

In certain states of disease, as in the collapse of cholera, or as a 
consequence of poisoning with alcohol, the temperature may be tem- 
porarily reduced many degrees below the normal standard. (Fig. 44.) 



Fig. 44. 



Fio. 45. 



BIS 

Isiaaiiiiil 



Very low temperature in rec- 
tum just before death. (Fin- 
layson.) 




Unusually high temperature just before death ; great 
exacerbation, with a rigor. (Finlaysox.) 



In like manner, under the influence of various diseases the tempera- 
ture (Fig. 45) may rise many degrees above the normal standard. 
Temperatures below 95° F. indicate collapse; temperatures between 
95° and 98° are called subnormal ; temperatures between 98.4° and 
101° constitute moderate fever ; temperatures between 101° and 105° 
constitute severe fever ; above 105° or 106° it is described as hyper- 
pyrexia, a condition sometimes observed in dangerous forms of cerebral 



FEVER 



69 



disease, infective fevers, or rheumatism. Fevers are said to be con- 
tinuous (Fig. 46) when the febrile temperature is constantly above the 



Fig. 46. 




Temperatures in a case of acute miliary tuberculosis in a boy, showing the type of a 
continued fever. Pulse 130-160; respiration 40 to 60 and 70. (Finlayson.) 

normal standard, with only the usual diurnal variations between morn- 
ing and evening temperature. Fever is said to be remittent (Fig. 47) 
when the diurnal oscillation exceeds the normal variation of 1.5° F. 
Fever is intermittent when the decline of temperature reaches the 

Fig. 47. 




Diurnal variations of temperature in a ease of remittent fever. 



normal standard with an interval of apyrexia (Fig. 48) between the 
paroxysms. Sthenic fever is a term applied to forms of fever that are 
characterized by vigorous reactions. Asthenic or adynamic fevers are 
characterized by depression and languor in all their features. 

Hyperpyrexia is a term that is applied to all cases in which the tern- 



70 



PRELIMINARY CONSIDER ATIOXS . 



perature exceeds 106° F. for any considerable time. Such fevers are 
usually asthenic and rapidly fatal. Relapsing fever signifies a return 



Fig. 48. 




Daily paroxysms in intermittent fever. Quotidian ague,- temperature in axilla. 

(Finlayson.) 

of the febrile phenomena after their apparent disappearance (Fig. 49) 
in particular forms of infective disease. 

Fig. 49. 



igmiHHI!«!!IIi!!Hii 

IlffiilPRIIIHlli 

iillREIii 

liliiilSlgiiii 

Mil 

Temperature in relapsing fever. (Wundbblich.J 

Symptoms of Fever. One of the most typical forms of fever is fur- 
nished by the paroxysm of intermittent malarial fever. It commences 



FEVER. 



71 



with a sensation of discomfort, great thirst, depression, disposition 
to yawn and stretch, accompanied by a feeling of chilliness, with dis- 
tinct rigors, although the temperature of the body is actually rising. 



Fig. 50. 




Fig. 51. 



Gradual rise of temperature at the beginning of enteric 
fever. (Finlayson.) 

The extremities are cold, the pulse is small 
and wiry from contraction of the arterial 
coats. In young children the rigors some- 
times reach the severity of a convulsion, 
which replaces the chill that is experienced 
by adults. 

This first stage of the fever may occupy 
one or two hours, in intermittent fever, or it 
may be prolonged over several days, as in 
typhoid fever (Fig. 50). When thus pro- 
longed the sensation of chilliness alternates 
with paroxysms of heat. At the expiration 
of the period of invasion, the fever passes 
into a stage of continuous progress called the 
fastigium. This may last a few hours only 
in intermittent malarial fever, or it may be 
prolonged for two or three weeks (Fig. 51) 
in typhoid fever. When thus prolonged the 
type of fever is continuous. There is con- 
stant elevation of temperature, the skin feels 
hot, sometimes dry and burning, sometimes 
moist and warm, the eyes may be red, the 
cheeks flushed, the mouth hot and dry, the 
tongue red, pointed, and covered with fur. 
The surface of the tongue may be either 
white, yellowish-brown, or dark in color; 
finally, in severe cases, drying up and becom- 
ing converted into mahogany-colored scales 
that crack open, and are smeared with blood 
from the mucous membrane of the mouth. The teeth also become cov- 
ered with a thick brownish paste that dries and hardens, constituting 
what is called sordes. Similar collections derived from the breath may 



Temperature in a case of en- 
teric fever. (Finlayson.) 



72 



PRELIMINARY CONSIDERATIONS. 



obstruct the nasal passages, causing the patient to breathe through the 
mouth, thus adding to the dryness and disorder of that cavity. Respi- 
ration is usually accelerated as the temperature rises. It may be dis- 
turbed by cough in certain complications of disease. The movements 
of the heart become more frequent, and are less vigorous as the rate of 
the pulse rises. In asthenic cases it becomes very frequent, small and 
feeble. There is loss of appetite, frequently nausea and vomiting, 
more or less complete arrest of digestion, constipation or diarrhoea, and 
a change in the quantity and quality of all the gastro-intestinal secre- 
tions. The urine diminishes in quantity, becomes highly colored, its 
specific gravity increases, and it is often excessively acid. The func- 
tions of the nervous system are more or less disordered. The mind 
may become clouded; delirium supervenes, and may deepen into sopor, 
terminating in coma and death. The course of delirium varies accord- 
ing to the temperament, age. and sex of the patient, being more fre- 
quent and of less importance in young and nervous subjects than in 
patients of the opposite type. Pain in the form of headache, rachi- 
algia. neuralgia, and a feeling of soreness in the muscles and extremities 
is usually experienced. In severe cases merging toward a fatal termi- 
nation, muscular twitching and jerking of the extremities, the so-called 
•subsultus tendinum, is often observed. Death may occur in any stage 
of the fever as a direct result of its cause, or as a consequence of the 
exhaustion produced by its duration. 

The third stage of the fever is the period of defervescence and con- 
valescence. It is sometimes ushered in by crisis (Fig. 52). when the 



Fig. 52. 








Crisis. Temperature in lobar pneumonia. 
Sudden crisis on eighth day ; pseudo-crisis 
on fourth day. (Wuxderlich.) 



Lysis. Temperature in broncho-pneu- 
monia. Gradual fall extending over four 

days. ( WUNDERLICB.) 



fever suddenly leaves the patient, the temperature falls to the normal or 
below the normal standard, and all the other morbid symptoms exhibit 
amelioration. Such crises may be witnessed in the decline of pneu- 
monia, typhus fever, relapsing fever, and intermittent fever. It is 
often accompanied by copious perspiration, diarrhoea, and other critical 



FEVEK. 73 

discharges. Usually, however, the decline of fever is gradual and 
may occupy a number of days. This mode of defervescence is called 
lysis. (Fig. 53.) It is the form of decline that is witnessed in typhoid 
fever. 

Etiology of Fever. Fever may be caused by simple irritation of 
the nervous system, as in certain cases of hysteria in which delicate 
and nervous patients exhibit a febrile reaction, usually of brief dura- 
tion, as a consequence of almost any excitation of their nerves. Such 
fevers are called neurotic or transient fevers. Among the most com- 
mon consequences of inflammation is a fever which is apparently due 
to an infection of the nervous centres with certain products of in- 
flammation that find their way into the general circulation of the body. 
Such fevers are called inflammatory. 

If the blood be contaminated by the introduction of septic materials 
or the products of putrefaction, a violent febrile reaction ensues. In- 
vasion of the body by certain microorganisms, and contamination of 
the blood by their excreta, will produce fever. In this way the so- 
called infective fevers are produced. 

Pathology of Fever. The heat of the body is maintained by the 
oxidation of its tissues. It is probable that in a simple organism mere 
increase of oxidation would be sufficient to produce the phenomena of 
fever, but in a large and complicated structure, like the animal body, 
the febrile movement is a more complex process. Increase of tempera- 
ture may be caused by increased oxidation and liberation of heat within 
the body ; by diminished dissipation of heat from the body ; by the 
coexistence of both conditions ; or by diminished dissipation of heat 
coexistent with reduced production. 

These varying conditions depend upon the regulative influence 
exerted by the nervous centres over the processes of heat-production, 
distribution, and dissipation. It has been shown by experiment that 
in and adjacent to the corpus striatum are located nervous centres 
that govern these processes. 

Excitation of these centres through the medium of the cerebrum 
itself may produce disturbances of temperature, as in hysterical fever. 
Derangement of the functional activity of these and other nervous 
centres by contamination of the blood with the products of inflamma- 
tion may also disturb the temperature, and produce the phenomena of 
inflammatory fever. And, going still further, the action of blood that 
has been contaminated with the excreta of various microorganisms may 
give rise to the phenomena of specific infective fevers. 

Results of Fever. Great importance has been attached to the 
effects of a prolonged temperature upon the nutrition of the tissues. 
Cloudy swelling and fatty degeneration of the elements of the tissues 
are frequently observed; the voluntary muscles undergo colloid degen- 
eration in many of the infective fevers. Muscles thus affected exhibit 
within the sarcolemma irregular masses of a hyaline substance derived 
from a degenerative transformation of the muscle fibre. 

The Prognosis in fever depends upon the severity of the symptoms 
and upon their duration. General increase and continuous elevation 
of temperature is of more serious import than a remittent or inter- 



74 PRELIMINARY CONSIDERATIONS. 

mittent course. If the evening temperature does not rise above 104° 
or 105 c F.. the prospect of recovery is favorable, but temperatures that 
exceed those figures for any length of time indicate the probability of 
a fatal termination. Asthenic conditions, marked by a rapid and feeble 
pulse, even though the temperature e. indicate a state 

of danger. High temperature of the I y\ with coldn- 

the extremities is an unfavorable indication. Xor is the process of de- 
fervescence without its attendant perils. Crisis may become merged in 
fatal collapse, as may be sometimes observed in the defervescence of 
pneumonia. A medium temperature, the pre >n of a fair degree 

of secretory and digestive i moderate and unwavering pulse, 

the absence of serious derangements of the nervous system, and the 
non-existence of complicating liseases, furnish the m ble basis 

for a favorable prognosis. 

Treatment. The principal indication for treatment in fever if 
assist :Le organs whose function has been deranged by the cause of the 
this purpose it is necessary to have regard for the gen- 
eral management of the patient. Perfect cleanliness of the whole 
body and of its surroundings is of importance. The most perfect 
ventilation of the apartment in which the patient lies must be secured. 
Er ; : and quiet, and skilful nursing, with proper diet, are indis- 
ble. 

The elevation of temperature that marks the course of fever is not 
an unmixed evil, yet it is customary to attempt its reduction. The 
most efficient means for the reduction of temperature is found in the 
application of cold water to the suface of the body. By this method. 
heat is rapidly abstracted from the body : and the local effect of cold 
water upon the cutaneous nerves :ses a beneficial effect upon the 

central nervous system, and upon the organs under its influence. 
Cold water may be applied by sponging the surface of the body with 
tepid wate ::ually cold, if the patient does not 

shrink from such an application. Cold eompresses :r rubber 
containing cold water may be applied to the chest and abdomen. Ice- 

_ 3 may be in like manner applied to the head, and cold water may 

be made to circulate through coils of tubing adapted to the body : but 

the most effectual method consists in the use : die sold bath. The 

patient should be placed in a tub containing water at the temperature of 

hich may then be cooled down "to 65° or 60 = F. If the 

patie: _ - I shiver, he should be immediately removed, rubbed 

dry. and placed again in bed. In this way the temperature may be 

— veral deg nd the bath must be repeated as often as it 

figure. Almost as efficient, and often more 

convenient, is the employment of the cold wet pack. 

The use of medicinal agents ice. not only in the reduction 

of temperatur ibution to the comfort of the patient. 

Quinine, in doses of fifteen grains, has folly depressing effect 

upon temperature : it is especially useful in malarial fevers. Salicylic 
acid and its compounds are almost equally specific in the treatment of 
rheumatic fevers. Inflammatory fevers are favorably influenced by 
reratram viride. and gelsemium : and in inflammations of the 



FEVER. 75 

respiratory organs tartar emetic is also useful. Antipyrine, phena- 
cetine, acetanilide, and exalgine are useful as general antipyretic 
agents. The efficiency of many of these agents, such as quinine, 
aconite, and tartar emetic, is considerably increased by the concurrent 
administration of opiates. Diaphoretics, like Dover's powder, sweet 
spirits of nitre, and the liquor ammonii acetatis are often serviceable 
for the relaxation of the skin and the promotion of gentle perspiration. 
Opiates are especially indicated for the relief of pain, and in small 
doses they prevent the fretful irritability that is so exhausting to a 
feeble patient. In like manner various saline solutions, such as citrate 
of potassium, citrate of lithia, and other effervescing draughts are 
refrigerant, but their use should be discontinued whenever they be- 
come disagreeable to the patient. Purgatives are most valuable at the 
outset of the fever. It is often well to preface all treatment with 
several half-grain doses of calomel followed by a saline cathartic, like 
a Seidlitz powder, Rochelle or Epsom salts, or the various laxative 
mineral waters. 

Solid food should be forbidden, and the diet should consist of liquid 
preparations. Cold water may be allowed. Milk is the model article 
of diet, but should never be given beyond the power of the digestive 
organs to accomplish its digestion. Frequent examination of the 
stools is therefore necessary to ascertain the efficiency of the digestive 
function. Beef-tea, animal broths, gruels, peptonized foods, eggs, and 
raw oysters may often be used with advantage. During the course of 
long-continued fevers the amount of food must be increased beyond 
what is needed in the early stages of the disease. 

Alcoholic stimulants are not as necessary during the course of fevers 
as was formerly supposed. Only in long-continued and asthenic cases 
is alcohol needed. It should be administered in small quantities, at 
regular intervals, and the quantity given should rarely exceed six or 
eight ounces of whiskey or brandy in the course of twenty-four hours. 
The breath of the patient should never become saturated with alcohol, 
and its administration should be checked whenever the odor of alcohol 
is noticeable in the breath. Dryness of the tongue, increased heat, 
greater rapidity of the pulse and respiration, accompanied by low 
muttering delirium, nausea, and vomiting, indicate an excessive alcoholic 
stimulation. Diminished intensity of fever is the only indication of 
benefit from alcoholic stimulants. 

Particular symptoms of fever sometimes require special attention. 
Severe headache may be relieved by cold applications to the head. 
For elderly patients, or those who are extremely feeble, warm affusions 
are often preferable. Inflammatory fever with head symptoms may 
require the application of leeches to the temples, or cups between the 
shoulders, followed by blisters in the later stages of the fever. Active 
delirium is an indication for sedatives and hypnotics, while low mut- 
tering delirium is an indication for the cautious use of stimulants and 
opiates, especially in the delirium of old people unattended by pulmon- 
ary obstruction. If sleep is not procured by the use of cold applica- 
tions and the ordinary antipyretic measures, it must be obtained by 
the use of hypnotics. In sthenic cases ten grains of Dover's powder 



76 FEVER. 

are often sufficient, or a twelfth of a grain of tartar emetic^added to a 
grain of opium, or to a quarter of a grain of morphine, will be found 
useful. Five drops of the tincture of aconite with a quarter of a 
grain of morphine forms an excellent substitute for the foregoing prep- 
arations. In asthenic cases, camphor should be combined with an 
opiate, as in the opium and camphor pill ; but in all cases of inter- 
ference with respiration, opiates should be administered with great 
caution. Hydrate of chloral, sulphonal, paraldehyde, the bromides, 
tincture of hyoscyamus, tincture of belladonna, cannabis indica, and 
various compounds of these drugs, are found useful. 

The restless wakefulness of low fevers must be combated by the 
administration of food such as milk, egg-nogs, brandy and egg, with 
opiates and stimulants. Carbonate of ammonia, sulphuric ether, 
aromatic spirits of ammonia, camphor, capsicum, musk, caffeine, and 
nux vomica must be used in failure of the heart. Food and stimu- 
lants, if not retained by the stomach, can be given by injections into 
the bowels. The bladder should be carefully emptied with a catheter, 
if necessary. Bedsores must be prevented by cleanliness, proper 
bedding, and the employment of a water-bed in severe cases. Con- 
valescence from fever requires great care in the matter of diet and 
fatigue. Restorative remedies and tonics must be furnished with a 
liberal hand. A change of locality is often attended with the best of 
results. 



PART II. 

PARASITIC AND INFECTIVE DISEASES. 



DISEASES CAUSED BY ANIMAL PARASITES. 
CHAPTER I. 

INTESTINAL WORMS. 

Diseases affecting the surface of the body should first engage the 
attention of the student. These are fully described in the standard 
works on dermatology. It will be found that a considerable number 
are caused by the action of animal and vegetable parasites upon the 
cutaneous investment of the body, but the action of parasites is not 
limited to its external surface ; the alimentary canal may become 
infested by parasites of animal and vegetable origin. The vegetable 
parasites will be considered in the portion of this work that treats of 
the infective diseases. 

Nematoid Worms. 

Lumbricoid Worms. (Ascaris Lumbricoides.) 

Description. These worms inhabit the small intestines. They 
resemble in size and shape the common earth-worm. (Fig. 54.) The 
male is about nine or ten inches long ; the female, from eighteen to 
nineteen inches in length. They are of a pink color ; the mouth has 
three rounded lips. The posterior extremity of the male is curved and 
furnished with two sexual prominences. The genital opening of the 
female is near the middle of the body ; the eggs, which are estimated 
at about sixty millions in number, are round. It has been thought 
that these eggs must undergo development outside of the human body, 
but later investigations indicate that such development is unnecessary, 
that they only need introduction into the alimentary canal, where they 
readily germinate. Discharged from the bowels with the fecal evacu- 
ations, they preserve their vitality for an indefinite length of time, and 
probably find their way back into the human intestine through the medium 
of drinking-water. It has been observed that they are more frequently 
encountered in persons who do not drink filtered water. They are 



78 



PARASITIC AXD INFECTIVE DISEASES. 



most frequently found in the intestines of children, and are sometimes 
discovered in the biliary passages, and in other ducts that communicate 

with the alimentary canal. Thus 




B 




B. Egg of asearis lum- 
brieoides. \ 250. (Bris- 
rowi. 



they may find their way into the 
stomach. oesophagus, the nasal pas- 
sages, the larynx, the Eustachian 
tube, and even into the lachry- 
mal canal, and the cavities behind 
the face. Ordinarily but one or 
two worms occur, but sometimes 
they are voided in large numbers, 
or mav even obstruct the intes- 
tine by their accumulation. Ab- 
scesses and tumors connecting with the intestines 
sometimes contain these parasites, and they have 
thus gained access even to the urinary passages. 

Symptoms. Lumbricoid worms frequently exist 
in the intestines without producing any morbid 
symptoms, but sometimes their presence excites 
various disturbances of the nervous system, princi- 
pally involving the digestive functions, giving origin 
to salivation, itching of the nose, diarrhoea, dyspep- 
sia, palpitation of the heart, cough, vertigo, and vari- 
ous other anomalous cerebral disturbances. Epi- 
leptiform and hysterical convulsions have been 
observed. These various disturbances appear to be 
produced by nervous irritation occasioned by the 
excretions of the worm, rather than by their mere 
presence in the alimentary canal. 

Treatment. The bowels should be evacuated 
with castor oil. and. for a day previous to the ad- 
ministration of the vermifuge, the patient should be 
restricted to a scanty liquid diet. Santonin is :he 
most successful agent for the expulsion of the para- 
site. It mav be given in doses oi one to five grains 
the worms are expelled, and 
appear in the feces. It may 
bit of bread and covered with 
be given without difficulty to 
Older patients can take it in 
the form of pills, or mixed with small doses of cas- 
tor oil. which is said to increase its efficiency. Care 
must be taken to avoid excessive doses, as the drug 
sometimes causes vertigo and other disagreeable ner- 
Unnecessary alarm may be avoided by informing the 
of the patient that the urine will become yellow 
under its influence, and, if voided into a vessel that contains any alkali, 
will exhibit a bright pink or scarlet color. 



be given 
every morning until 
their ova no longer 
be sprinkled upon a 
butter, when it can 
the youngest child. 



A. Asearis lumbri- 

coides. (Nat. sir 

vous symptoms, 
parents or friends 



INTESTINAL WORMS. 



79 



Oxyuris Vermicularis. 



Fig. 55. 




Description. A minute round, white, thread-like worm. (Fig. 55.) 
The male is about one-sixth of an inch long ; its posterior extremity 
lies in a coil and contains the sexual organs. The 
female is nearly half an inch long ; the rounded an- 
terior extremity contains the mouth with three lips ; 
the sexual orifice is near the junction of the anterior 
and middle thirds. The posterior extremity is very 
thin and pointed. The eggs are exceedingly numer- 
ous, flat on one side and rounded on the other. They 
do not mature until they have been expelled from 
the intestine and have found their way into the 
stomach of another individual. Desiccation does not 
destroy their vitality. They develop in the small in- 
testine, where the union of the sexes takes place. The 
males then die and are eliminated with the faeces, 
while the females pass onward into the caecum, where 
their eggs are matured. They then pass downward 
into the rectum, from which they frequently find 
their way out into the vagina or even into the urethra 
and bladder. At night they often make their appear- 
ance upon the cutaneous surfaces around the anal 
orifice. The principal inconvenience caused by their 
presence is an intense itching of the parts about the 
anus. Their presence may cause an inflammation of 
the rectal mucous membrane, and in excitable patients various nervous 
disturbances are sometimes observed. 

Treatment. Perfect cleanliness about the anal orifice must be 
secured. The rectum and large intestine should be washed out every 
day with a copious injection consisting of common salt, or any other 
alkaline salt, dissolved in tepid water. After the bowels have been 
thus evacuated, the rectum should be filled by injection with some 
bitter infusion, like quassia, wormwood, or boneset. Injections of gly- 
cerin and water, in equal parts, are useful. Santonin may be given 
internally, and anal irritation may be relieved by the nightly appli- 
cation of mercurial ointment, which may also be introduced into the 
rectum. 



Thread-worm. a. 
Female. b. Male. 
X 10. c. Actual 
length of female. 
d Egg. X 250. 
(Bristowe.) 



FlLARIA. FlLARIA MEDINENSIS, OR GUINEA-WORM. 

Description. In warm climates a species of filaria, or hair-worm, 
remarkable for its length, which varies from fifteen to thirty-five or 
forty inches, is sometimes found under the skin of the legs and feet, 
sometimes in the scrotum or on the body, and occasionally in the supe- 
rior extremities. Its presence gives origin to tumors of an elongated 
and cord-like shape, which present an appearance of inflammation. 
After a time they open and discharge a serous liquid. The hair-like 
worm can then be discovered in the cavity, and can be extracted by 



80 



PARASITIC AND INFECTIVE DISEASES 



careful manipulation. It has been thought that it enters the areolar 
tissues by perforation of the skin, but other observers believe that it 
finds its way with drinking-water into the stomach, from which it 
penetrates the tissues. 



Filaria Sanguinis Hominis. 

Description. The full-grown filaria is about four inches long, and 
has a very slender neck and rounded head. (Fig. 56.) It is especially 

Fig. 56. 
A B 

/ 




A. Filaria sanguinis hominis. X 250. (After Lewis.) 

in the lymphatic system that it is found, but its 
embryos may be also discovered in the blood during 
the hours of the night. During the day it cannot be 
found in the blood, unless the patient sleeps in the 
daytime and wakes at night. These embryos are 
about one-third of a millimetre in length. The head 
is rounded ; the posterior extremity slender and 
pointed. This larval creature is surrounded by a 
thin sheath in which it moves freely. When circu- 
lating in the blood, the embryonic parasites may be 
absorbed into the body of the mosquito, where they 
undergo further development. The sheath of the 
embryo is dissolved, and at the end of a few hours 
the filaria has increased its length threefold. The 
mouth and alimentary canal become fully developed, 
sexual organs appear, and the worm is ready for life 
in the water which receives the dead body of its host. If now such 
water be used for drinking purposes, the parasite enters the alimentary 
canal of man, and once more finds its way into the circulatory channels 
of the body. Multiplying in the bloodvessels and in the lymphatic 
canals it produces great distention of the lymphatics, giving rise to 
elephantiasis of the scrotum, hematuria, chyluria. and various lymph- 
atic tumors. Other species of filaria have been discovered among the 
inhabitants of the tropics, especially in Africa. 



B. a. Female filaria. 

(Nat. size.) b. Ovum. 
X 250. (Cobbold.) 



INTESTINAL WOKMS 



81 



Trichina. 



In the larval state this parasite is found in the muscles of swine and 
other animals. Flesh thus infected, if taken into the stomach of man, 
conveys the embryos into the alimentary canal, where they develop. 
The males are about three millimetres in length, while the females are 
nearly twice as long. Fecundation and development having taken 
place in the intestines, the parent worms die, 
while their offspring in the embryonic stage 
penetrate the intestinal walls, and find their 
way into the muscles throughout the body, 
where they may be discovered about fourteen 
days after the introduction of the encysted 
embryos into the stomach. Having reached 
the muscles, the little worms coil themselves 
between the muscular fibres, and surround 
themselves with an envelope (Fig. 57), formed 
externally of connective tissue, and lined with 
a substance similar to chitine. Within this 
cyst the worm lies in a spiral coil. At the 
end of from three to six months these cysts 
become infiltrated with calcareous salts, giving 
an appearance of minute white granules scat- 
tered through the muscles. In this condition 
the parasites retain their vitality for a number 
of years, and if the mass of flesh in which they 
are imbedded find its way by any chance into 
the stomach of another animal, they are speed- 
ily liberated by the solution of their envelopes 
to renew the cycle of change. The liberation 
of trichinae in the intestine produces an inflam- 
mation of its mucous surface, causing abdominal pain, diarrhoea, and 
sometimes vomiting, with loss of appetite, and the phenomena of 
intense fever. A few days later, the limbs become painful, the mus- 
cles stiffen and are sometimes contracted, the face and whole body 
become slightly cedematous, the abdomen swells, the tongue dries, 
there is copious perspiration ; dyspnoea and a sensation of constriction 
about the thorax are experienced. The patient falls into a typhoid 
condition often mistaken for typhoid fever. As the parasites become 
encysted, the fever subsides, but diarrhoea may persist, the lungs become 
©edematous, the whole body grows dropsical and pallid ; sometimes bed- 
sores form, and the patient may die at the end of one or two months. 
Recovery, however, takes place in the majority of instances. About 
12 per cent, of the cases are fatal. 

Pathological Anatomy. Very little can be discovered after death, 
excepting the presence of the parasites in the muscles. When diarrhoea 
has preceded death, the evidences of inflammation may be discovered in 
the small intestine, and the liver may have undergone fatty degeneration. 
The spleen is not affected. The lungs frequently present evidence of 

6 




Trichina spiralis. En- 
cysted trichina. X 100. 
(Bristowe.j 



82 



PAKASITIC AND INFECTIVE DISEASES. 



localized pneumonia. The parasites are most numerous near the ten- 
dinous extremities of the muscles, and are most frequently found in the 
muscles adjacent to the alimentary canal. The muscular fibres present 
a granular appearance. Sometimes there is waxy degeneration ; and 
the amount of connective tissue is considerably increased in the neigh- 
borhood of the parasitic cysts. 

Treatment. Thorough cooking destroys the vitality of the encysted 
parasites. It is the use of raw or partially cooked pork that is most 
dangerous. Such meat should never be consumed without previous 
inspection with the microscope, or the most thorough cooking. If 
trichinosis be suspected, the alimentary canal should be thoroughly 
evacuated with calomel and jalap, or with castor oil. After invasion 
of the muscles has taken place, there is no specific remedy for the dis- 
ease, and each case must be treated on general principles, with anodynes 
for the relief of pain, warm baths, gentle friction of the surface, and 
attention to every complication that may arise. 



Trichocephalus Dispar. 

This parasite is sometimes found in considerable number in the small 
intestine, and especially in the caecum. It is nearly two inches in 
length. The anterior three-fifths of the worm 
forms an exceedingly delicate and hair-like tube 
containing only the oesophagus. (Fig. 58.) The 
posterior portion is very much thicker, contains 
the principal organs of the body, and, in the male, 
is coiled in a flattened spiral. It has been sup- 
posed to originate various nervous disturbances, 
and even inflammation of the caecum, but nothing 
very definite is known regarding the matter. The 
eggs of the parasite are taken into the stomach 
with drinking-water. They are oval in shape, 
and present a minute prominence at each extrem- 
ity, by which they may be easily recognized with 
the miscroscope. In about a month, the embryos 
are developed, and have reached maturity. The 
symptoms are generally negative, and the treat- 
ment is the same that is recommended for the 
expulsion of oxyuris. 




Trichocephalus dis- 
par. a. Female. b 
Male. (Nat. size.) c 
Egg. X 250. (Bris- 

TOWE.) 



Anchylostomum Duodena le (Dochmius Duodenalis). 

This parasite is from six to eighteen millimetres long. The 
females are about twice as large as the males. (Fig. 59.) The mouth 
is furnished with four teeth upon the ventral margin, and two upon 
the dorsal. With the aid of this apparatus, it attaches itself firmly to 
the mucous surface of the small intestine, where its continual suction 
deprives the patient of blood, and frequently occasions intestinal hemor- 
rhage. Digestion suffers, and profound anaemia ensues. The eggs 
are evacuated with the feces, and mature in water outside of the body. 



INTESTINAL WORMS 



88 



Infection is caused by drinking water that contains the eggs of larva?. 
In Egypt, in Italy, and in Central Europe, these parasites have been 
discovered among brick-makers, coal-miners, and workmen who have 
been compelled to drink impure water. It has been ascertained that 
the intense anaemia common among such workmen is due to infection 
with these parasites. The workmen employed in the construction of 



Fig. 59. 



Fig. 60. 




Anchylostoma duodenal e. a. Female. 
b. Male. X 10. c. Actual length. (Bris- 

TOWE.) 



Anguillula stercoralis. Female with eggs 
and embryo. X 85. (Perroncito.) 



the St. Gothard tunnel furnished many examples of this disease, which 
may be readily detected by examination of the feces and discovery of 
the ova with the aid of the microscope. 

Treatment should consist in the administration of mercurial 
cathartics, followed by santonin until the ova can be no longer detected 
in the evacuations. The parasitical anaemia may be relieved by the 
exhibition of iron, arsenic, and tonics. 



84 PARASITIC AND INFECTIVE DISEASES. 



Anguillula Intestinalis and Angulllula Stercoealis. 

These minute, eel-shaped parasites, one or two millimetres in length, 
exist in great numbers in the duodenum and jejunum of certain inhabi- 
tants of the tropical regions of the world. In Cochin-China. the 
West Indies, South America, and even in Italy, their presence has been 
determined, and it is generally supposed to be the cause of an obstinate 
form of diarrhoea. (Fig. 60.) So rapidly do the parasites multiply in 
the intestine, that patients have been known to evacuate more than a 
hundred thousand of these creatures in a single day. A long con- 
tinued diet of milk constitutes the most effectual means of cure. 



STRONGYLUS GrIGAS. 

This is the largest of the nematoid worms. The male is from six to 
seventeen inches long : the female is from seventeen to forty inches in 
length. Most commonlv found in the kidnev and bladder of the horse, 
cow. and dog, it has occasionally been observed in the corresponding 
organs of man. 

Cestoid or Tapeworms. 

Many different species of tapeworm have been described, but the 
principal forms are four in number: 1. Taenia solium. 2. Ta?nia 
mediocanellata. 3. Taenia echinococcus. 4. Bothriocephalus latus. 
The different species of tsenia may exist in the human body under two 
different states — the cystic and the vermiform. Of these, the last is 
developed in the intestinal canal, while the first may be found in any 
organ of the body. 

T-exia Solium. 

This worm occupies the small intestine. Its head is octohedral in 
shape (Fig. 61), about the size of a small pin-head, furnished at the 
sides with four large suckers, by the aid of which it attaches itself to 
the mucous membrane of the intestine. Anterior to these is the rostrum, 
a contractile organ which can be protruded or retracted at will. It is sur- 
rounded by a double row of booklets, from twelve to fifteen in each row, 
of which each one closely resembles in shape the claw of a cat. These 
accompany the movements of the rostrum. The neck i« about an inch in 
length, transversely marked, and exceedingly slender. Behind this are 
developed the separate segments of the animal. These segments or 
proglottides are protruded from the neck, one after another, the oldest 
being largest and most distant from the head. Each segment consists 
of a whitish, translucent flattened mass, provided with contractile tis- 
sues, a water-vascular system for the circulation of liquids, and a 
reproductive apparatus that represents the organs of both sexes. The 
segments are closely linked together in such a way that their vascular 
canals communicate with each other. Each link or segment contains a 
complete and independent reproductive apparatus, provided with male 
and female organs. The ovaries occupy the greater portion of the 



INTESTINAL WORMS. 



85 



segment, with seven or eight lateral branches communicating with a 
central canal or uterus which opens upon one of the margins about the 
middle of the segment. These marginal orifices are placed alternately 
upon opposite sides of the successive segments. Thus constituted, the 
length of the worm may reach several feet, lying coiled in the small 
intestine. Single segments and considerable sections of the worm may 
become detached, passing with the feces through the large intestine. 

Fig. 61. 




Tamia solium and cysticercus. a, b, c, d. Different parts of tapeworm. (Natural size.) 
c,f. Cysticercus cellulosae. (Natural size.) g. Head. h. Head seen from above. X about 
50. i. Sucker. X 250. j. Hooklet attached. X 250. k. Egg. X 250. (Bristwe.) 

The eggs, voided in great numbers, find their way into the water of 
the earth, and may thus be introduced into the stomach with unfiltered 
drinking-water. There they are digested, and the embryonic worms 
are set free. Thus liberated, the embryo consists of a minute vesicle 
called the proscolex. Upon one side of this little sac appear three pairs 
of spicule, the rudiments of the crown that surrounds the rostrum of 
the mature animal. Penetrating the walls of the stomach or intestine, 
the embryo migrates to other parts of the body. There it becomes 
fixed and develops the larval form. The head assumes a shape like that 
of the parent worm, and is inverted within the cyst-like body. In this 
condition the parasite is called a scolex. It becomes surrounded by a 
connective-tissue sac, and remains imbedded in the flesh or organs of 
the animal, where its presence may be discerned by the naked eye, 
giving to the muscular tissue a speckled appearance known as measles. 

After remaining for a year or more in the living animal, the scolex 
dies, becomes infiltrated with calcareous matter, and shrinks almost out 
of sight. These scolices were formerly supposed to be distinct para- 



86 PARASITIC AND INFECTIVE DISEASES. 

sites, to which was given the name of cysticercm celhdosce. The 
cysticerci have been found in every part of the body, and have been 
observed in the eye. They vary in bulk from the size of a mustard- 
seed to that of a small pea. In the brain they may originate circum- 
scribed inflammations which sometimes result in the formation of 
abscesses, producing epileptiform convulsions and various forms of 
cerebral paralysis. 

If, now, the flesh of an animal containing these larval parasites be 
eaten raw or partly cooked, the scolices are liberated in the stomach. 
Having reached the small intestine, the head is protruded from the 
larval sac and becomes attached by its suckers to the intestinal wall. 
The sac disappears, and the worm grows by the budding of segments in 
succession from its neck. In a few months the well-known form and 
size of the mature worm are reached. The life of the animal in this 
situation may be indefinitely prolonged, ripened segments and ova being 
continually separated and discharged from the intestine. 

Symptoms. Once developed in the small intestine, the tapeworm 
may exist in the alimentary canal for a long period of time without the 
occurrence of any symptoms denoting its presence, excepting the ap- 
pearance of its segments and ova in the feces. Sometimes, however, 
the ordinary symptoms of chronic catarrhal enteritis are present. The 
general symptoms of nervous irritation, such as cardiac disturbances, 
muscular twitching, uneasy sensations in the head, thorax, and abdomen, 
and even epileptiform convulsions, have been noticed. 

Treatment. Since the larvae of taenia solium are, for the most part, 
derived from measly pork, the avoidance of such food is imperatively 
demanded ; and animals, like hogs, that are raised for human consump- 
tion, should not be allowed access to food or water that may be con- 
taminated with fecal substances. 

When the worm has found lodgment in the intestine, treatment should 
not be undertaken until the presence of the parasite has been demon- 
strated by the appearance of its segments in the excrements. The 
indications for treatment are destruction of the life of the worm, and 
its removal from the bowels. A variety of drugs have been recom- 
mended for this purpose. For two or three days before the administra- 
tion of taeniacide drugs, the diet should be restricted to milk and 
bread, and a dose of castor oil or of compound licorice powder may be 
given the day before the commencement of specific treatment. Having 
thus prepared the patient, the selected drug may be given in the morning 
w r hile the patient is yet fasting ; and in a few hours, if the worm is not 
discharged, another cathartic dose of castor oil may be given. The 
favorite remedy is the ethereal extract of the root of male fern. This 
may be given in doses of half a drachm, or a drachm, repeated twice at 
intervals of half an hour. It may be suspended in milk, or may be 
given in gelatin capsules, as otherwise it is likely to prove nauseating. 
The evacuated worm should be received in a vessel of water, in which it 
can be washed and carefully examined for the discovery of the head, 
for if that portion of the worm remain attached to the intestinal wall, 
the body of the animal will be rapidly reproduced. If the head does 
not appear with the remainder of the worm, the cure must remain 
doubtful for three months or more, until sufficient time has elapsed for 



INTESTINAL WORMS. 



87 



the reappearance of ripened segments in the feces. Treatment should 
not be resumed before that time. 

Oil of turpentine to the amount of one or two fluidounces, made 
into an emulsion, is sometimes employed with success. A decoction of 
the fresh bark of the pomegranate root, prepared by infusing three or 
four ounces of the bark for twelve hours in a pint of water, and then 
reducing the amount one-half by evaporation over a slow fire, may be 
given in divided doses during the course of an hour, and may be followed 
by castor oil. The only objectionable feature of its administration is 
the liability to nausea, which may be avoided by giving the liquid in 
small and frequent doses. 

Tannate of pelletierine, an alkaloidal derivative of the pomegranate 
root, is a most effectual but rather expensive remedy for tapeworm. The 
dose is from seven to twelve grains, to be followed by castor oil. 

Kousso, and its alcoholic derivative koussine, have been used exten- 
sively in the Orient. Pumpkin seeds furnish an oil which may be used 
in doses of half an ounce or an ounce. The perisperm, or meats, ex- 
tracted from four ounces of the fresh seeds and rubbed in a mortar into 
a paste with sugar and milk, will be found useful, forming a not dis- 
agreeable preparation which may be taken in divided doses, at short 
intervals, to the amount of a pint. This remedy possesses the advantage 
of easy preparation and no violent or disagreeable action. 




T^nia Mediocanellata. 

In the larval state, this parasite inhabits the flesh of the ox. (Fig. 
62.) The ova are swallowed by the animal with its food or drink ; the 
embryos are liberated in the stomach 
and intestines, whence they pene- FlG - 62 - 

trate into the muscles, where they 
remain as scolices or cysticerci. In 
the mature condition the worm in- 
habits the small intestine of man, like 
the taenia solium similarly derived 
from measly pork. The head of the 
worm has no rostrum and is destitute 
of hooklets, but attaches itself by 
suckers to the mucous membrane. The 
worm grows by the devolopment of 
segments precisely like taenia solium. 
The vascular apparatus is also similar, 
but the ovaries in each segment are 
much more branched, and their ex- 
ternal orifice is placed irregularly 
alternately upon opposite margins of 
the successive segments. The full- 
grown worm may be developed in the 
course of fifty or sixty days, and may 
reach a length exceeding that of the 
entire intestinal canal. The ripened segments are discharged with the 
feces, or not unfrequently escape alone through the anus, a peculiarity 




Taenia mediocanellata. a, b, c. Dif- 
ferent parts of tapeworm. (Natural 
size.) d. Head. X 10. e. Egg. X 250. 
(Bbistowb.) 



83 



PARASITIC A XI) INFECTIVE DISEASES. 



by which this species of worm is characterized. Among beef-eating 
people, especially among those who are partial to underdone meat, this 
is the most common form of tapeworm. Delicate children who have 
been fed upon scraped raw beef are not unfrequently thus infected. 

Treatment. The symptoms and treatment of this species of tape- 
worm are identical with what has been already described in the pre- 



ceding section. 



TAENIA ECHIXOCOCCUS. 



This species of tapeworm may be frequently seen attached to the 
valvules conniventes in the small intestine of the dog. (Fig. 63.) It 
consists of only four segments, and is a quarter of an inch in length. 
Like tienia solium, its head is provided with four suckers. [a rostrum. 



Fig. 63. 











A. Taenia echinococcus. a Tfenii 
X 10. b. Ovum. X 250. 



B. Echinococci. or. Group of echinococci still at- 
tached to ruptured brood-capsule. X 1 00. b. Hook- 
lets. X 250. (Bristo- 



and a double circle of booklets forty or fifty in number. The terminal 
segment contains the ova. and when detached is immediately replaced 
by another. The ova pass from the body with the feces, and may easily 
find entrance into the stomachs of people who associate freely with dogs. 
The liberated embryo passes from the stomach into the intestines, and 
thus finds its way into the tissues of the body. There becoming 
encysted, it is transformed into the hydatid cyst. These may vary in 
size from that of a small pea to the dimensions of a large orange. 

The hydatid cyst is composed of a thick, laminated, translucent, and 
highly elastic membrane, the ectoeyst. (Fig. 64.) This is provided 
with a thin cellular lining called the endocyst. Upon the surface of 
the endocyst are developed numerous little processes which soon present 
a rounded cavity, lined by a delicate membrane. These constitute the 
proligerous vesicles. The original sac is called the parent cyst, the 
secondary processes are called daughter cysts, within which may be 



INTESTINAL WORMS, 



89 



Fig. 64. 




Hydatid cyst. X 100. (Bristowe ) 



developed a tertiary growth of granddaughter cysts. From the lining 
membrane of the daughter cysts grow the larval scolices of the future 
worms. These resemble in structure the head of the mature taenia. 
So long as the hydatid cyst remains alive, the embryo scolices remain 
attached to the germinal membrane, but after the death of the cyst they 
become detached and float free in the liquid contents of the daughter 
vesicles. Such hydatids are most frequently found in the liver, but 
they also exist in the muscles, in 
the bones, in the central nervous 
organs, and in the subcutaneous 
areolar tissue. Such hydatid 
tumors always cause great dis- 
turbances of the health, and ma} r 
occasion the death of their host. 
The symptoms that are caused by 
their development in the central 
organs of the body are those that 
result from mechanical interfer- 
ence with the functions of the 
invaded organs, and from the 
atrophy that follows compression 
through enlargement of the tumor. 
If the brain be invaded, the symptoms are identical with those that 
follow the development of other tumors in that organ. Upon the 
surface of the liver, a hydatid tumor may sometimes be recognized by 
its globular form, by its elasticity, and by the peculiar thrill imparted 
to the hand, if the tumor be rapidly percussed. Such tumors occa- 
sionally suppurate, and their contents may be discharged like those of 
an ordinary abscess. The discovery of the characteristic hooklets of 
the parasite would suffice to identify the disease. 

Tre a.tment. Medical treatment seems to accomplish little or nothing 
against hydatid disease. The only opportunity for relief must be 
reached through the methods of surgery, when the tumor occupies an 
accessible cavity. 

BOTHRIOCEPHALUS LATUS. 

Bothriocephalus is the largest of the tapeworms (Fig. 65), sometimes 
reaching fifty feet in length. Its head is oval, without hooklets or 
rostrum, and has on each side a longitudinal slit that replaces the 
suckers of the taeniae. The neck is long and slender, transversely 
marked, and gives origin to the segments of the body, which succeed 
one another as in taenia. The breadth of these segments is greater 
than their length. The genital orifices are placed near the middle of 
the ventral surface instead of upon the margins. The male orifice is 
separate from the female, and is placed a little nearer the anterior ex- 
tremity of the segment. The uterus occupies the centre of the mass, 
and consists of an extremely contorted tube. The eggs, oval in shape, 
opening at one extremity by a lid-like valve, are developed in fresh 
water. Consumed by fish, they hatch in the alimentary canal, liber- 
ating an embryo covered with vibratile cilia?, and furnished with six 



90 



PARASITIC AND INFECTIVE DISEASES. 



Fig. 65. 



booklets. This embryo finds its way into the muscles or other organs 
where it passes into the larval stage. The flesh of fish containing these 
scolices conveys the embryonic parasite into the stomach of man. where 
the larva is liberated, and in the intestine is developed into the mature 
worm. It is consequently among fish-eating inhabitants of countries 
adjacent to the ocean that this parasite is most 
often encountered. Several other species of 
bothriocephalus have been occasionally encoun- 
tered in different localities, and in Japan there 
is a species of which the larval form reaches a 
length of about twelve inches. 

Symptoms and Treatment correspond with 
those that have been already recommended in 
connection with taenia solium. 

Trematodes or Fluke-worms. 





Like the tapeworms, these parasites are gen- 
erally hermaphrodite. They possess a water- 
vascular system opening by a single orifice near 
the posterior extremity of the body, which con- 
sists of but a single segment. There is an ali- 
mentary canal opening by a single orifice in the 
anterior portion of the body. There is a single 
sucker at the anterior extremity, and another 
near the middle of the ventral aspect. The 
worm is propagated by eggs, which hatch out- 
side of the animal and liberate a ciliated embryo 
that swims freely in water. These embryos 
penetrate the bodies of fresh-water snails, in 
which they are transformed into larvae called sporocysts. These sporo- 
cysts contain- bud-like processes which develop into another form called 
redia. In this form the embryo reaches the liver, where it undergoes 
further development, producing within itself new forms that, in some 
respects, resemble the parent worm. Having reached this stage of 
development, the parasite finds its way from the tissues of the snail into 
the water, where after a time it attaches itself to the adjacent weeds 
and grass, and passes into an encysted condition. Taken with food 
into the stomach of graminivorous animals, the embryo finally reaches 
the liver of its host, where it is developed into the mature fluke-worm. 



^^ 



Bothriocephalus latus. 
a, b. Different parts of 
tapeworm, c. Head. X 
10. d. Egg. X 250. 
(Bristotte.) 



DlSTOMA HePATICUM. 



This is the common liver-fluke found in the sheep and in other 
domestic animals (Fig. 66) inhabiting the liver and bile-ducts, and 
branches of the portal vein, from which it sometimes finds its way into 
other cavities and into subcutaneous abscesses. Only rarely has it been 
found in man. It is a flat, tongue-shaped creature, about one inch long 
and half an inch wide. Its external surface is covered with minute 
scale-like processes. In sheep it is the cause of a disease known as the 



INTESTINAL WORMS 



91 



rot. In the human subject it produces an inordinate appetite and a 
sensation of fulness in the epigastrium. The liver and spleen become 
enlarged, there is a sanguinolent diarrhoea, the patient becomes drop- 
sical and dies. 

Fig. 66. 




a. Distoma hepaticum. X 2.5. b. Eggs of distoma he]:>aticum. 



200. (Leuckart.) 



The diagnosis may be confirmed by an examination of the stools, 
which contain the eggs of the parasite. Several other species of dis- 
toma have been noted in different parts of the world, as in the island 
of Formosa, where nearly one-sixth of the population are infected by 
distoma Ringeri, which develops in the branches of the pulmonary 
artery and produces dangerous haemoptysis. 

Distoma H^matobium, or Bilharzia. 

This species is very common in Arabia, in Egypt, and in other parts 
of Africao (Fig. 67.) It inhabits the bloodvessels, especially those of 
the liver and kidneys, in which it feeds upon the blood. The sexes 

Fig. 67. 





A. Distoma haematobium, the female lying within the male. X 10. B. Eggs of distoma 
haematobium. X 150. (Lkuckart.) 



occur in separate individuals. The female is a slender, thread-like 
worm about three-fourths of an inch long, and the male is about one- 
third less. The eggs are ovoid, and are furnished with a spinous 
process at one extremity. They are deposited in the capillary vessels 
of the liver, the intestines, the kidneys, the ureters, and bladder, pro- 



92 



PARASITIC AXD INFECTIVE DISEASES 



ducing in 



the intestinal canal lesions similar to those observed in 
dysentery. In the urinary tract their presence occasions frequent and 
dangerous hematuria. 

The diagnosis depends upon the discovery of the spinous ova in the 
feces and in the urine. No specific treatment has yet proved successful. 



CHAPTER II 



PROTOZOA. 



Various forms of arnceba have been recently discovered in the 
mucus of the intestines (Fig. 68), vagina, and bladder of patients in 



Fig. 63. 






1_5 




A. Balantidium eoli. (Claus.) a. Mouth, b. Nucleus, c. Starch granules, d. Foreign 
body in the act of extrusion. B. Cercomonas intestiualis. v Dayaixe.) C. Trichomonas 
vaginalis. (Kolliker.) D. Trichomonas intestiualis. (Zexker.) 

different parts of the world who suffer with various diseases of those 
organs. Certain representatives of the sporozoa, notably eoccidium 



Fig. 




Coccidia from the human liver. 
X 300. b, c. X 1000. (Leuckart.) 



oviforme, have been observed in man. 
(Fig. 69.) These are unicellular or- 
ganisms, ovoid in form and provided 
with a nucleus, that remain immovable 
throughout the entire period of de- 
velopment. They exist in the inter- 
stices, or Avithin epithelial cells of the 
tissues, where they become encysted 
and produce spores. They have been 
overlooked by reason of their close 
resemblance, in certain stages of de- 
velopment, to the nuclei of the epi- 
thelial cells and the leucocytes which 
they infest. They have been observed 
in the bile-duct- and in tumors of the 



MALARIAL FEVER. 93 

liver. In the skin, certain species of this parasite produce cutaneous 
diseases, such as Paget' 's disease of the nipple, acne cornea, and possibly 
molluscum contagiosum. Similar parasites have recently been dis- 
covered in various forms of epithelial tumors, in uterine cancers, in 
cirrhosis, and atrophy of the liver. These discoveries seem to open a 
wide field for future research. 

In the fecal discharges of typhoid fever, chronic diarrhoea and 
cholera, a minute animal parasite, cercomonas intestinalis, has been 
observed. The pathological significance of these and similar monad 
parasites has not yet been precisely ascertained. Klebs has recently 
advanced the hypothesis that the blood corpuscles in certain cases of 
pernicious anaemia are destroyed by various protozoa. The same 
author affirms that goitre and cretinism originate in the presence of 
certain flagillariae in the drinking-water of districts where these dis- 
eases prevail. 



CHAPTER III. 

MALARIAL FEVER. 

Malarial fevers are caused by the action of malaria, of which the 
nature will be considered in a subsequent paragraph. They are 
encountered chiefly in the tropical regions of the earth, and, during 
warm weather, in the temperate and sub-tropical zones. Generated in 
swampy localities, they are for the most part experienced in low lands 
lying near the seashore, or along the borders of large rivers. Appar- 
ently dry soils sometimes yield malaria, but they are underlaid by a 
layer of clay or rock that prevents proper drainage, so that the sub- 
soil is actually in a swampy condition. Tracts of land that are alter- 
nately overflowed with water and dried by the heat of the sun are 
prolific sources of malaria, especially when first disturbed by the pro- 
cesses of agriculture or by extensive excavation for any other pur- 
pose. A dry season following a wet favors the production of malaria, 
Changes in the mode of drainage, and interference with the free circu- 
lation of water, by the construction of dams or the draining of ponds, 
may liberate malaria in long-settled countries where previously it had 
been unknown. 

Long settlement and perfect drainage, on the contrary, may banish 
malarial diseases from localities originally scourged by them. 

Malarial diseases are grouped under four principal forms : 1, inter- 
mittent fever ; 2, remittent fever ; 3, pernicious fever) 4, malarial 
cachexia. Of these, intermittent fever is the mildest form, and is the 
most frequent in northern climates, where the disease only prevails 
during the heated months of the year. Remittent and pernicious 
fevers are most commonly experienced in tropical and in sub-tropical 
countries. 



94 



PARASITIC AXD INFECTIVE DISEASES. 



Intermittent Fever. This variety of malarial fever, commonly 
called fever and ague, is of frequent occurrence during the later 
months of summer in localities where malaria is endemic. It some- 
times occurs during the winter and spring, but such cases result from 
previous infection during the summer, since it has been observed that 
malaria is developed only when the mean temperature of the air is 
continuously above 60° F. The fever consists of a succession of 
paroxysms, separated from one another by an interval of variable 
duration during which the temperature of the body is normal. The 
ordinary form of intermittent fever of moderate type is characterized 
by the occurrence of a paroxysm on every other day. This is called 
tertian intermittent fever. (Fig. 70.) When the type of fever is more 



Fig. 70. 





11 HI 



mm:: 1 1\ m 



mi 

hup; III 

P2 llllli! 





Intermittent fever — tertian ague; temperature in axilla. (Fivlaysox.) 

severe, the paroxysms recur every day, constituting the quotidian fever. 
Sometimes the paroxysm recurs upon the fourth day, constituting a 
quartan fever. There is also a liability to recurrence after an interval 
of six or seven days. These constitute the regular types of inter- 
mittent fever, but sometimes there are reduplications of the paroxysms. 
Quotidian fevers overlap one another so as to produce two paroxysms 
each day. Tertian fevers may also overlap so as to produce daily 
paroxysms with characteristics different from those of the regular 
quotidian type. Thus a double tertian may exhibit similar paroxysms 
on the first and third days, with another pair occurring upon the 
second and fourth days, but differing from the paroxysms of ordinary 
quotidian fever by irregularity, either in the hour of recurrence or in 
the characteristics of the paroxysms. 

Other variations in the succession of the febrile paroxysms have been 
noticed, but are without particular importance. 

Description of the Disease. For several days previous to an 
attack of the fever the patient may experience sensations of lassitude, 
headache, loss of appetite, and vague disturbance of the health. These 



MALARIAL FEVER. 95 

sensations may recur for a limited period every day, or every other 
day, until they finally culminate in a fully formed paroxysm. Again, 
the onset of the fever may be sudden, especially if the patient has been 
exposed to a very concentrated form of malaria. The paroxysm 
usually commences shortly before noon, but it may begin at any hour 
of the day or night. It consists of three successive stages : the cold, 
the hot, and the sweating stage. 

The cold stage. The surface of the body is cold ; the countenance 
is .pale and pinched ; the skin is contracted and roughened by spasm 
of the cutaneous muscles. The pulse is small and feeble ; respiration 
may be hurried; there is headache; the tongue is pale; saliva deficient; 
often there may be nausea and vomiting ; the patient shivers and feels 
cold, though the temperature of the body is actually rising above the 
normal degree. This stage may continue from a few minutes to several 
hours. Its duration is usually about an hour. 

The hot stage. The patient ceases to shiver, and experiences an 
agreeable cessation of cold and tremor. A sensation of warmth gradu- 
ally pervades the whole body, and deepens into a dry and burning 
heat. The face appears flushed; the eyes become injected and red; 
the arterial muscles relax ; the pulse becomes full and bounding; respi- 
ration is hurried, and the temperature rises to 106° F., or even 
higher. There is headache and backache, sometimes even delirium, 
and in children there may be convulsions. The urine, if voided, is 
scanty and high-colored, and its nitrogenous constituents are increased. 
Loss of appetite is complete, and there is great thirst. This stage may 
continue from two to eighteen or twenty hours. In regular intermit- 
tent fever the shorter period is more common. 

The sweating stage. Perspiration appears first upon the forehead, 
and gradually moistens the entire surface of the body. Sensations of 
pain, heat, thirst, nausea, and general discomfort subside, and the 
patient gradually returns to apparent health. At the close of the 
paroxysms the temperature may fall one or to degrees below the nor- 
mal standard, but it soon returns to the characteristic level of health, 
and the patient appears to be well until the commencement of the next 
paroxysm, which, in the quotidian type of fever, recurs upon the next 
day, but in the tertian type is postponed until the third day. This 
period of apparent health between the close of a paroxysm and the 
commencement of the next, is called the intermission of the fever. 
The period occupied by a single paroxysm and intermission is called 
the interval of the fever. Long-continued paroxysms and brief inter- 
missions indicate a severe form of fever, while brief paroxysms and 
long intermissions indicate the opposite type. 

If the evolution of the fever proceeds with increasing severity, the 
paroxysms tend to recur at an earlier hour of the day ; such fevers are 
said to anticipate their paroxysms. In that way a tertian fever may 
be transformed into a quotidian. When, on the contrary, a fever is 
becoming milder, its paroxysms may be successively postponed to 
later hours of the day, and thus a quotidian fever may become a 
tertian. 



96 PARASITIC AND INFECTIVE DISEASES. 

Pathological Anatomy. Since the mortality of intermittent fever 
is very low, it is not often that the opportunity presents for examina- 
tion of the bodies of patients who have died with the uncomplicated 
disease. The spleen and liver are similarly enlarged, and contain an 
increased quantity of pigment. The muscular fibres of the heart are 
pale and softened, as a result of the elevated temperature experienced 
during the paroxysms. The red corpuscles of the blood are diminished 
in number, while the white corpuscles have become more numerous. 
The power of coagulation is greatly reduced, and the serum that 
separates from the imperfectly organized clot is stained with the 
haemoglobin of the disintegrated corpuscles. But the most character- 
istic change consists in the presence in the blood of the protozoon, 
Plasmodium malarioe, described elsewhere. 

Treatment. During the paroxysm of intermittent fever the 
patient should be made as comfortable as possible. This may be 
effected by the recumbent position. During the cold stage he may 
be warmly covered in bed, and may be allowed warm and stimulating 
drinks. Nausea may be relieved by the application of mustard to the 
epigastrium, and discomfort may be greatly diminished by the hypo- 
dermic injection of morphine and atropine. The paroxysm may be, in 
fact, aborted by the administration of one or two half-drachm doses of 
chloroform swallowed with ice-water. If nausea and vomiting do not 
contra-indicate, ten grains each of calomel and jalap may be given 
with advantage at the commencement of this stage ; or, if nausea be 
considerable, twenty grains of calomel laid upon the tongue may be 
followed by one or two soda-mint tablets. 

During the hot stage the comfort of the patient will be considerably 
increased by cold sponging of the surface, by cold drinks, by the use of 
aerated waters, or by the frequent exhibition of scruple doses of potas- 
sium bicarbonate in iced lemonade. 

The complete establishment of the sweating stage is the signal for 
the administration of quinine. This should be given in divided doses 
until twenty or thirty grains, according to the severity of the case, 
have been taken. It may be given in several large doses — ten grains 
every six hours — or in three-grain doses every hour until the full 
amount has been administered. If possible, the drug should be given 
in solution or in wafers. Pills are objectionable, because they are often 
insoluble in the stomach. Various disguises may be necessary in deal- 
ing with children, to whom the tannate of quinine may be given in 
syrup of licorice or in the form of tablets compounded with chocolate. 
If the stomach be very irritable, the drug may be administered by 
enema, having first washed out the rectum with clear water. If the 
case be very urgent, the acid hydrochlorate or the acid hydrobromate of 
quinine may be dissolved in a small quantity of water and administered 
hypodermically in doses of one or two grains, often repeated. If, for 
any reason, quinine cannot be employed, Fowler's solution of the arsenite 
of potassium may be used as a substitute. This should be given in 
five-drop doses, repeated every four hours, for a number of days. By 
this means a recurrence of the paroxysm will usually be prevented. 



MALARIAL FEVER. 97 

To obviate the danger of relapses, it will be found expedient to admin- 
ister the following pill : 

R . — Acid, arsen. \ .. 

Strych. sulph. / M % T - J* 

Aloin X -- " 

Podophyllin J ■ o • J- 

Quin. sulph. . . . . . . ^ss. 

01. res. piper, nig. ..... gtt. xxx. — M. 

Ft. pil. no. xxx. 

Sig. One pill three times a day. 

Warburg's tincture, in drachm doses, repeated three or four times a 
day, is a favorite remedy among the English in India. 

The patient should be kept saturated with quinine for more than a 
week, to avoid the danger of relapse ; and larger doses of the drug may 
be given at the end of each weekly interval, until the health is fully 
restored. 

Remittent Fever. This fever, frequently called bilious fever or 
remittent fever, differs from intermittent fever in the fact that the suc- 
cessive paroxysms are not separated from one another by a period of 
normal temperature. The temperature remits, but does not fall to the 
normal standard. It is the common form of malarial fever in warm 
climates and in localities where the malarial poison is highly concen- 
trated. It is consequently the scourge of the tropics and of the newly 
settled localities in the southern and western portions of the United 
States. Like intermittent fever, the types of the disease may be 
quotidian, tertian, quartan, etc. The paroxysms are sometimes brief, 
and sometimes so long continued that the remission can be scarcely 
observed. They sometimes manifest the successive stages of cold, 
heat, and sweating, as in intermittent fever; but in other cases 
the distinction of the separate stages is not well defined, the tendency 
to continued high temperature overpowering the cold stage and the 
sweating stage. In some instances it is difficult to distinguish between 
severe intermittent and mild remittent fever. Generally, however, the 
course of the disease is marked by a greater intensity of all the mani- 
festations, indicating a degree of intoxication more profound than exists 
in intermittent fever. 

Description of the Disease. For two or three days before the 
access of the fever the patient experiences some degree of depression 
and disturbance of the functions of digestion, with languor, low spirits, 
and disinclination to exertion. The symptoms of disordered digestion 
and deficient nerve-power are the most prominent. Sometimes, how- 
ever, the attack is quite sudden, especially if an unacclimatized patient 
have been exposed to severe heat and exhaustion in a malarious locality. 
The initial paroxysm commences quite abruptly, but the cold stage Is 
usually of short duration, quickly yielding to the hot stage, which is 
prolonged beyond the corresponding stage of intermittent fever. There 
is headache ; severe pain in the back and limbs ; a flushed face ; red- 
ness of the eyes; dryness of the skin; large pale tongue, often indented 
at the edges ; dryness of the mouth ; frequently intense nausea and 
vomiting of bilious matter. Sometimes there is hiccough, or a dis- 



98 PAKASITIC AND INFECTIVE DISEASES. 

tressing sensation, as if a hair or a piece of a feather had been lodged 
in the pharynx ; the pulse rises rapidly, and the temperature soon 
reaches 106° or 108° F. Sometimes the nose bleeds ; the bowels are 
usually constipated, or there may be a bilious diarrhoea ; the urine is 
acid, high colored, scanty, with an increase of nitrogenous elements. 
This stage continues from six to eighteen hours ; then a gentle perspi- 
ration gradually appears upon the surface, all the symptoms of high 
fever and restlessness subside, and the patient falls into a quiet sleep. 
The temperature gradually descends, but does not fall to the normal 
standard. In ordinary cases the hot stage continues from about noon 
until midnight ; the temperature then begins to fall, and the remission 
is established shortly before daylight. In severe cases the remission 
may be very brief or scarcely discoverable ; in mild cases it may con- 
tinue until late in the forenoon. The hot stage is then repeated, and 
the same round of symptoms is renewed. If the course of the fever is 
marked by increasing severity, the remissions grow shorter and the 
paroxysms become more intense. As the fever subsides toward con- 
valescence the remissions grow longer, until complete intermissions 
separate the successive paroxysms, as in ordinary intermittent fever. 
During the course of the fever delirium may appear. Sometimes this 
may deepen into stupor or coma, terminating in death. More fre- 
quently the patient is only restless, wakeful, and uneasy. 

The duration of the disease is exceedingly variable. It may con- 
tinue for two or three weeks before the commencement of improvement. 
It may terminate fatally at any time after its commencement. It may 
gradually subside into a typhoid condition of uncertain duration and 
result. A favorable termination may occur by crisis, the final 
paroxysm ending abruptly with a copious perspiration or a critical 
discharge from the bowels or kidneys. More frequently, however, 
recovery takes place, with a gradual subsidence of all the symptoms 
that mark the acute stage of the disease. The dry mouth becomes 
moist ; the tongue begins to clean at the tips and edges ; nervous 
symptoms subside ; sleep becomes more refreshing ; temperature be- 
comes gradually less, and convalescence is finally established. When 
the disease assumes the intermittent type during convalescence, the 
daily paroxysms may recur for a considerable period of time, but they 
become less severe, and finally disappear altogether. 

In many of the severe forms of the fever, during the second week 
of its course the regularly remittent type of the disease is merged in a 
typhoid condition. The pulse increases in rapidity while diminished in 
strength. The temperature is high and unevenly distributed ; the 
tongue becomes dry, brown, and hard ; the teeth and lips and lining 
of the mouth are coated with sordes ; the bowels may be either con- 
fined or frequently and unconsciously evacuated ; secretion of urine 
becomes scanty, and the bladder may be distended by retention ; the 
mind is obscured by delirium that is rapidly merged in stupor and coma ; 
the body emaciates, and death may occur at any time between the 
second and fifth or sixth week. Recovery sometimes takes place even 
from this desperate condition. The most favorable indications under such 
circumstances are found in the subsidence of nervous symptoms and the 



MALARIAL FEVER. 99 

restoration of secretion, as shown by a return of moisture to the mouth, 
and the disappearance of sordes and fur from the tongue. In such 
cases the tongue generally throws off its coating, leaving the surface 
smooth and red, and often presenting a glazed appearance. Recovery 
under such circumstances is usually very tedious. 

Diagnosis. Typical cases of remittent fever may be easily recog- 
nized, but if the typhoid condition be developed it may be difficult to 
distinguish this from a corresponding condition in typhoid fever. The 
mode of onset, the rapid development of high temperature, the remit- 
tent course of the disease, the absence of diarrhoea, rose spots, and 
tympanitic distention of the abdomen, favor the diagnosis of remittent 
fever. In countries where yellow fever prevails the question of dif- 
ferential diagnosis may arise. From yellow fever it must be dis- 
tinguished by its longer course, by its distinctly remittent type, by the 
rarity of hemorrhage from the stomach, intestines, and urinary passages, 
and by the marked influence of quinine in its treatment. 

Pathological Anatomy. The liver and the spleen are much 
enlarged and deeply pigmented ; the gall-bladder is frequently filled 
with thick and tar-like bile ; the mucous membrane of the stomach and 
intestines is thickened and softened ; the red corpuscles of the blood 
are greatly diminished in number ; the muscular fibres of the heart 
are pale and softened. 

Prognosis. Despite the severity of the fever its mortality in tem- 
perate climates is not very high. In the malarious regions of the 
tropics, on the contrary, the mortality from this fever is very great. 
During the civil war, from 1861 to 1865, the mortality in the United 
States army from remittent fever was 13.45 per thousand, but in trop- 
ical countries, and without treatment, the mortality is far greater. So 
much depends upon these various factors that it is impossible to assign 
any universal rate of mortality. 

Treatment. The bowels should be evacuated as speedily as possible 
with the aid of a mercurial cathartic. A dose of calomel and jalap, or 
three or four compound cathartic pills, will be sufficient for this pur- 
pose. If the stomach be irritable, and there is bilious vomiting, perhaps 
associated with bilious diarrhoea, ten or twenty grains of calomel may 
be placed upon the tongue to be washed down with an effervescing 
draught or with ice-water, and a mustard plaster should be applied to 
the pit of the stomach. This may be followed in the course of two or 
three hours with an effervescent solution of the citrate of magnesia, a 
Seidlitz powder, or any other saline purgative. As the temperature 
rises, antipyrine may be given in five grain doses that may be repeated 
sufficiently often to reduce the temperature and to favor moderate per- 
spiration. If the circulation manifest any sign of failure, phenacetine 
should be preferred to antipyrine. Nausea may be greatly relieved by 
the frequent administration of minute doses of morphine — the thir- 
tieth of a grain every fifteen minutes until relieved. With this may 
be conjoined corresponding doses of dilute hydrocyanic acid. During 
the hot stage the skin may be cooled by frequent sponging and by the 
use of cooling beverages. As soon as the temperature begins to sub- 
side, and the remission is established, quinine should be administered, 



100 PARASITIC AND INFECTIVE DISEASES. 

as in the treatment of the similar stage of intermittent fever. During 
the course of the disease the patient should be kept under the full influ- 
ence of quinine, administered in divided doses to the extent of from ten 
to twenty grains during the twenty-four hours. Restlessness and 
wakefulness may be combated with the various hypnotics, such as 
chloral, sulphonal, bromidia, paraldehyde, Hoffmann's anodyne, Dover's 
powder, and the various opiates. The typhoid condition requires sup- 
porting treatment, with careful nursing and feeding. The diet should 
be restricted to liquids, milk, gruel, toast-water, and thin broths. Egg- 
nog and alcoholic stimulants will be required in cases that are 
marked by typhoid symptoms. Cardiac failure, gastralgia, hiccough, 
and kindred nervous disturbances will be relieved by organic stimu- 
lants, of which capsicum, camphor, nux vomica, and small doses of 
opium, are the most valuable. During convalescence the bowels are 
often constipated, requiring the use of compound rhubarb pills or laxa- 
tive enemata. The appetite may be somewhat deficient, needing the 
stimulus of simple bitters, like the compound infusion of gentian, or 
the elixir of calisaya bark, or any other similar vegetable preparation. 
Tonic doses of quinine should be continued for a long time, as recom- 
mended after intermittent fever. 

The patient must not be allowed to gratify his appetite in an unrea- 
sonable manner. The diet must be restricted at first to bread, roasted 
potatoes, farinaceous food, with eggs, broth, and the tenderest meats in 
small quantity, gradually ascending the scale from the lighter varieties 
of food to the coarser and more substantial articles. 

Pernicious Fever. During the paroxysms of intermittent and remit- 
tent fevers a tendency to more than ordinary prostration, stupor, car- 
diac failure, or gastro-intestinal disturbance is sometimes remarked. 
In these cases the danger of the fever is correspondingly increased, and 
may reach a degree that is designated by the term pernicious fever, a 
form of the disease that without energetic treatment is usually fatal. 
The pernicious tendency is ordinarily manifested in the course of what 
appears to be a common malarial fever. Suddenly the symptoms of 
danger are displayed. They may principally affect the cerebral organs, 
the respiratory and circulatory organs, or the gastro-intestinal tract. 
The cerebral form of the disease is characterized by stupor deepening 
into coma, similar to that which is manifested in the course of apoplexy. 
Convulsions have also been observed. From similar conditions of apo- 
plexy this form of pernicious fever must be distinguished by the absence 
of hemiplegia, and by its manifestation during the course of a malarial 
fever, or in a person obviously exposed to malarial infection. 

In the cardiac form of the disease the medulla oblongata is really 
the seat of oppression, with consequent tendency to failure of respira- 
tion and circulation. In this form the patient complains of cold or of 
heat, though actual rigors are usually absent. The skin is pale, the 
countenance pinched, perspiration drips from the surface of the body, 
the voice becomes husky, respiration is shallow and inefficient, the pulse 
disappears. The patient usually becomes unconscious before death. 
From this condition of great prostration he may partially rally with 
the subsidence of the paroxysm, which, if neglected, will be again 



MALARIAL FEVER. 101 

renewed until a fatal termination is reached, a third paroxysm being 
rarely survived. In the gastro-intestinal variety the symptoms closely 
resemble those of Asiatic cholera. The nausea and vomiting that fre- 
quently accompany an ordinary paroxysm are attended by the greatest 
degree of prostration. Occasionally there is hemorrhage from the 
different passages of the body. 

Treatment. Prompt recognition of the malarial origin of this dis- 
ease is imperative. The patient must be as quickly as possible saturated 
with quinine introduced hypodermically. The surface of the body 
should be covered with mustard poultices, and if the skin is cool and 
the circulation feeble, warm applications should surround the body, and 
hot whiskey and water be given internally. Tincture of capsicum may 
be given in drachm doses, frequently repeated, since the pungency of 
the dose is either not perceived, or is grateful to the patient. Opium 
and camphor may be given by the mouth if retained, otherwise mor- 
phine and atropine should be injected hypodermically. If the patient 
complain of burning heat, and especially if the temperature be elevated, 
much benefit may be derived from cold bathing, or even from the affu- 
sion of cold water over the body. After the subsidence of the paroxysm 
quinine should still be administered for the purpose of preventing sub- 
sequent paroxysms. The ordinary treatment for remittent fever will 
then be usually sufficient. Hematuria requires the additional employ- 
ment of aromatic sulphuric acid, gallic acid, and ergot in appropriate 
doses until the cessation of hemorrhage. 

Malarial Cachexia. Chronic exposure to malaria, especially during 
imperfect convalescence from malarial fever, develops a variety of morbid 
conditions that constitute malarial cachexia. The various forms of 
fever, either with or without treatment, may become merged into a 
chronic intermittent type, which may present the different stages of 
cold, heat, and sweating, or may be limited to a succession of undevel- 
oped paroxysms characterized by undefinable discomfort rather than 
by any pronounced phenomena. To this latent form the name " dumb 
ague " is usually given. Another common variety of cachexia consists 
in successive, periodical derangements of the gastro-intestinal functions. 
The patient suffers with chronic indigestion, enlargement of the spleen 
and liver, accompanied by anaemia, emaciation, and debility, and a 
universal pigmentation of the skin. Thus enlarged the spleen may 
occupy a considerable portion of the abdomen, constituting the well- 
known ." ague cake" of malarious countries. 

Neuralgia, especially involving the supra-orbital branch of the fifth 
nerve, is commonly experienced as a consequence of the anaemic state 
of the patient. All forms of intercurrent disease occurring in the 
victims of malarial cachexia assume a periodical character, marked by 
regular intermissions to a degree that has often led incautious observers 
to mistake such diseases for an irregular manifestation of malarial fever. 
Post-mortem examination of the victims of malarial cachexia reveals 
changes, chiefly in the liver and spleen, which are deeply pigmented 
with haematoidin derived from the destruction of the red corpuscles of 
the blood. The brain, the skin, and other organs of the body share in 



102 PARASITIC Ai\D INFECTIVE DISEASES. 

this pigmentation. Even the corpuscles of the blood contain pigment 
granules, constituting the condition called melancemia. 

Treatment. Removal from the malarious locality is the first requi- 
site for successful treatment. It is sometimes sufficient to effect a tem- 
porary change of residence. Children suffering with intractable inter- 
mittens may often be cured by the simple expedient of exchange of 
homes, for a short time, by two infected families. Violent excitement, 
nervous shocks, and deep emotion sometimes accomplish the same 
result, but if the cachexia be profound and of long duration, a complete 
removal of the patient to a healthful climate must be accomplished. It 
is worthy of note that in the medicinal treatment of such patients, 
large doses of quinine are comparatively ineffectual. Better results are 
reached through the use of arsenic, iron, and strychnine, combined with 
aromatics and gentle cholagogues, as in the pill previously recom- 
mended. The elixir of iron, quinine, and strychnine, or the elixir of 
iron, quinine, and arsenic, is an excellent preparation, and it may be 
administered in drachm doses after each meal, for many months. In 
all cases constipation of the bowels should be avoided, and the functions 
of the kidneys must be carefully maintained. Whenever antiperiodic 
remedies fail to produce an immediate or successful result, the kidneys 
should be stimulated for three or four days with alkaline diuretics, such 
as potassium acetate, citrate, or nitrate. A few medicinal doses of anti- 
pyrine will often be found serviceable as an introduction to antiperi- 
odic treatment in chronic forms of ague. Warburg's tincture is of great 
value in many cases. One of the most effectual means of restoration 
from the chronic indigestion and lithsemia that so frequently follow ma- 
larial fevers consists in the administration of strong nitric acid during a 
period of three or four weeks. Five drops of the acid should be diluted 
with six or eight ounces of water, and should be drunk by suction through 
a glass tube, in order to avoid injury of the teeth. This dose may be 
repeated three or four times a day with the greatest advantage. 
Chronic enlargement of the liver and spleen may be treated by daily 
inunctions over these organs with ointment of the biniodide of mercury. 
Exposure of the skin to sunshine or to the heat of the fire after inunc- 
tion adds to the efficacy of this proceeding. 

Etiology. The conditions under which malaria originates have 
been already considered. The nature of the infective poison demands 
attention. The volatile character of the infection has always been 
remarked. Rising from the surface of the soil with watery vapor into 
the upper regions of the atmosphere, the lower strata of air may be 
comparatively free from malaria during the daytime, but become heavily 
charged with the poison at night, when the vapors are condensed and 
descend in the form of dew. Hence the greater danger from exposure 
to the open air at night. Transportation of malaria by the wind has 
been frequently observed : residents upon the leeward side of a mala- 
rious swamp suffering severely, while residents upon the windward side 
escape. The interposition of a grove of trees or a considerable hill 
between such marshes and human habitations has also proved sufficient 
as a screen in the course of prevailing winds, so that the residents upon 
the leeward side of such a screen are efficiently protected from the 



MALARIAL FEVER. 



103 



malaria, which is projected above the level of their habitations with the 
ascending currents of air. Thus, it seems that the poison of malaria 
must be something that can be carried like smoke by moving currents 
of air. It is also to some extent capable of diffusion through the 
medium of water, and may thus enter the body with water that is 
drunk. But this mode of infection is less effectual than its introduc- 
tion through the respiratory passages. rs^^T^ 
A conviction of the particulate character of the infective matter of 
malaria led observers long since to microscopical examination of the 
air in malarious regions. Various forms of bacteria have been studied 
and considered as the infective agent. Notable among these researches 
are the investigations of the Italians who have experimented extensively 
with the air, the water, and the soil in the environs of Rome. But 
these researches have never carried conviction to the minds of all 
pathologists, and the bacterial origin of malaria still seems highly 
improbable. In 1881 a French army surgeon, named Laveran, pub- 
lished his discovery of a protozoic parasite in the blood of patients suf- 
fering with malarial diseases. To this parasite was given the name 
Plasmodium malarice or hcemoplasmodium. (Fig. 71.) It exists free 



Fig. 71. 




Plasmodium malarise from the different stages of a quartan fever, a. Red blood-cor- 
puscle including a small parasite, b, c, d, e. Pigmented plasmodia of different sizes 
occupying the interior of the red blood-corpuscles. /. Commencement of segmentation 
with central deposit of pigment, g. Plasmodium undergoing segmentation, h. Spher- 
ical division of Plasmodium, i, k. Two different forms of free plasmodia. (Golgi.) 

in the blood plasma, or applied closely to the substance of the red blood- 
corpuscles, either within or without their periphery. During a certain 
stage of its development it contains minute granules of blood pigment. 
It exhibits amoeboid movements, and is surrounded by a number of 
slender movable filaments or flagella. (Fig. 72.) These may become 
detached, and may float freely in the plasma. 

It is at the commencement of the febrile paroxysms that these para- 
sites are most numerous in the blood. They attach themselves to the 
red corpuscles, become charged with pigment, divide into segments 
which become motionless, often crescentic in form, and are broken up 
and carried away, apparently by the white corpuscles that discharge 
the pigmented mass into the spleen and the liver, which thus become 
loaded with pigment. With the commencement of each successive 



104 



PARASITIC AND INFECTIVE DISEASES 



paroxysm the hnematozoa again appear, probably as a successive gener- 
ation of descendants from the mature parasites which propagate them- 
selves through the medium of spore-like germs. These parasitic forms 
rapidly disappear under the influence of quinine. It has been sug- 
gested that the different types of malarial fever are conditioned by 
different varieties of the infective protozoon. Malaria may be commu- 
nicated to healthy individuals by the intra- venous injection of blood 
containing plasmodia, and the type of the fever thus communicated 
corresponds with the form exhibited by the patient from whom the 
blood was derived. 



Fig. 72. 




A. Spherical form of plasmodium. B. Sphere with movable filaments. B'. Lateral 
placement of the movable filaments, c. Detached filament. D. Spherical body filled 
with granules of pigment in active motion. E. Spherical body treated with osmic acid, 
showing the double contour of the mass. (Hallopeau.) 

Prophylaxis. In malarious localities the disease may be, to a 
certain extent, avoided by care in the matter of exposure to excessive 
heat, fatigue, and intemperance of all kinds. Warmth must be secured 
in every habitation, even in warm climates by the use of fires, at night, 
at least, if not needed during the daytime. Small doses of quinine, 
two or three grains at meal-time, taken daily during the period of 
sojourn in an unhealthy region, are an indispensable means of protec- 
tion against attacks of fever. In this way it may become possible to 
reside for years with safety in a place where health could not be main- 
tained for a single season without such prophylaxis. 



DYSENTERY. 105 



CHAPTER IV. 

DYSENTERY. 

Dysentery is a specific inflammation of the large intestine that 
prevails endemically in many tropical regions of the earth, and may 
occur epidemically in any part of the temperate zones where favoring 
conditions arise. More widely and frequently prevalent than cholera, 
yellow fever, or the plague, it destroys a larger number of victims than 
any or all of those diseases. During the civil war in the United States 
one-third of the admissions to the hospitals were caused by intestinal 
disorders of a dysenteric character. Everywhere, in all ages, it has 
been the scourge of armies, often arresting the march of victorious 
hosts and bringing to an inglorious termination the most promising 
campaign. 

Symptoms. The period of incubation is often absent. In other 
instances exposure to the specific contagion of the disease is followed 
by no morbid consequence for a long period of time. In the majority 
of cases the period of invasion is characterized by a slight diarrhoea, 
without fever or serious disturbance of the health. The occurrence of 
previous diseases, especially those that are malarial or scorbutic in 
their character, generally occasions a rapid development of the dysen- 
teric attack. The disease then commences abruptly with the charac- 
teristic symptoms ; severe paroxysms of colic {tormina), tenesmus, and 
frequent muco-sanguinolent stools. With this aggravation of the initial 
diarrhoea the abdomen becomes swollen, and a certain degree of fever 
appears. The patient complains of considerable debility ; there is loss 
of appetite and the power of digestion ; the urine becomes high-colored 
and scanty ; there is frequent pain in the colon, extending into the 
rectum and reaching into the anus, provoking a continual desire to 
evacuate the bowels, accompanied by a sensation as if something of a 
solid character must be expelled from the rectum. Occasionally small 
masses of faecal matter, covered with mucus and streaked with blood, 
make their appearance. But the principal result of the repeated and 
protracted efforts of the patient is the discharge of a small quantity of 
slimy matter containing more or less blood, and closely resembling the 
tenacious muco-sanguinolent expectoration of pneumonia. In certain 
cases this incessant effort causes a prolapse of the rectum itself. The 
frequent repetition of these paroxysms, sometimes occurring fifteen to 
twenty times every hour, renders sleep impossible. The patient rapidly 
loses flesh and strength ; the features collapse and express the utmost 
degree of weariness and pain ; but the intellectual faculties remain 
undisturbed. 

In moderate forms of the disease these symptoms continue four or 
five days, and then gradually decline ; pain subsides, the stools become 
normal, and the patient slowly returns to health. 



PARASITIC AND INFECTIVE DISEASES 

But in severe forms of dysentery as it assumes the epidemic charac- 
ter under conditions unfavorable to health, or as it prevails endemically 
in warm climates, the disea-T xmtinues with increasing gravity. The 
stage : n is now reached. The stools lose their 

mucous character, and become liquid in consequence of the destruction 
of the intestinal mucous glands. Fever continues and assun. 
typhoid character ; there is intense thirst ; the mouth becomes dry ; 
the tongue red. pointed, smooth, and shining from the loss of its 
epithelial covering; the abdomer. sinks, :enesmu- the sphincter 

ani muscle becomes so relaxed that the interior of the rectum is some- 
times visible through the patulous anus; the liquid stools xhale the 
: putrefaction, and consist of a sei - - .riguinolent fluid that 
resembles the washings of beef: the urine is scanty and sometimes 
suppressed, or is replaced by a few drops of a burning, purulent liquid. 
The voice becomes hoarse, enfeebled, and finally extinguished : the 
extremities grow cold: pain ceases. Hiccough supervenes: the pulse 
becomes more frequent and thready : respiration is accelerated : the 
face becomes Badaveroos, and death occurs from complete exhaustion, 
though the mind frequently retains its sonscions intelligence until the 
end of life. 

If the es not thus reach a fatal termination, the symptoms 

may gradually snbsi le, and recovery may occur. 

The rectum is the portion of the intestine in which the disease lir._ 
after the upper portions of the gut have return e " tc state :f health. 
In thr-r ases the stools resume their normal appearance and time of 
nation, but the fa?cal cylinders bear upon their surface muco- 
purulent and bloody discharges from the ulcerated surfaces over which 
they pass. 

In warm climates and under unfavorable conditions, acute dysentery 
ay likely to pass into the chronic form of the die rhieh may 

linger indefinitely, and may finally wear out the life of the patient. 
The passage from the acute form to the chronic form takes place by 
insensible degrees, so that it is difficult to define the limits between the 
i the disease. Among patients who have been previously 
debilitated by malaria, scurvy, intemperance, old age. and other causes 
of exhaustion, the dise e a chronic character from the 

very outset of the There is but little fever and comparatively 

slight abdominal pain : the intellect is undisturbed : the patient com- 
plains of weakness, and lies upon the side with the knees bent and the 
thighs drawn up against the belly. He experiences great sensitiv 
to changes of temperature: th>. - re no long* ged with blood, 

but are of a thin brownish-yellow color, often sero-purulent. and con- 
tain particles of undigested food. ] no longer colic r. 
mils, but the slightest exposure to cold, movement of the body, or even 
-allowing of food, is sufficient to provoke evacuation of the bowels. 
which are rendered especially painful by the inflammation and ulcera- 
tion of the anus. The appetite is preserved, but digestion and assim- 
ilation are almost completely arrested. The tongue resembles raw 
beef-steak : blood sometimes oozes from the mucous membranes of the 
mouth: the breath exhales a cadaveric odor: the skin becomes 



DYSENTERY. 107 

brown, rough, and almost scaly ; the mucous membrane of the bladder 
ulcerates ; the consequent vesical tenesmus is sometimes intolerable ; 
the scanty urine is loaded with mucus and pus. Emaciation is extreme, 
rivalling that of pulmonary consumption. During the last stages of 
the disease the limbs become cedematous; the eyes sink in their 
sockets ; purulent conjunctivitis and ulceration of the cornea sometimes 
occur ; the mouth and throat also become ulcerated ; the skin becomes 
necrotic wherever it is subjected to pressure over the bony prominences 
of the skeleton ; ecchymotic spots appear upon the skin ; erysipelas 
may attack the face ; the intellectual faculties finally give way, and 
the patient dies in the last degree of emaciation and exhaustion. 

Diagnosis. Acute dysentery may be distinguished from proctitis 
by an exploration of the rectum, hemorrhoidal swelling and inflamma- 
tion being present in simple inflammation of the rectum, while the 
graver disease is attended by acute ulceration. 

The rectal tenesmus that produces a discharge of sanguinolent 
mucus from the bowels a few days after childbirth, and the similar 
condition that is sometimes presented by the victims of stone in 
the bladder, can scarcely be mistaken for the symptoms of genuine 
dysentery. 

Chronic dysentery may be distinguished from cancer of the rectum 
by local examination. Chronic tubercular diarrhoea closely resembles 
chronic dysentery, but may be distinguished from that disease by the 
previous history of the patient and by the tubercular invasion of 
other organs. From the chronic diarrhoea of the tropics it may be 
distinguished by the early history. 

Prognosis and Mortality. Dysentery as it appears under con- 
ditions favorable to recovery in temperate climates is rarely dangerous 
or fatal. Under such circumstances it seems to be a self-limited dis- 
ease that terminates in recovery after one or two weeks. No disease, 
however, is more liable to relapse, for it does not protect against itself; 
and each successive attack increases the susceptibility of the patient to 
subsequent attacks. No disease is more easily aggravated by unfavor- 
able hygienic conditions or by cachectic states of the body. No disease 
tends to become more persistent and incurable the longer it is permitted 
to exist. By reason of the great variations in the conditions that con- 
trol the prevalence of the disease, its mortality exhibits a corresponding 
degree of variation. While in the acute dysentery of Europe the mor- 
tality does not exceed 6 per cent., in warm climates it rises to 25 per 
cent., and in certain epidemics it has been known to exceed 50 per 
cent. The mortality of chronic dysentery is about 80 per cent. 

Pathological Anatomy. After death from acute dysentery the 
mucous membrane of the large intestine appears swollen by an intense 
congestion which reaches to a variable distance up the course of the 
colon, and may invade the small intestine itself. The inflamed sur- 
face is covered with mucus mingled with blood that has escaped from 
numerous visible hemorrhagic points. Actual necrosis of the surface 
becomes apparent in certain parts of the mucous membrane. Two 
forms of inflammation may be differentiated, though frequently asso- 



108 PARASITIC AND INFECTIVE DISEASES. 

ciated together in the same patient : 1, the catarrhal form, and 2, the 
diphtheritic variety. 

The catarrhal form occupies the superficial structures of the mucous 
membrane, and is characterized by exfoliation of the epithelium, 
especially upon the prominent convolutions of that membrane. 

The diphtheritic form differs only from the first by a deeper infiltra- 
tion of the intestinal walls. This process may involve the whole sub- 
mucous structure, even invading the muscular layer. The glandular 
organs seated in the intestinal wall take part in the inflammatory pro- 
cess, and become centres of ulceration. From these points of departure 
the mucous layer may become undermined by suppuration and necrosis. 

In chronic dysentery the ulcerative process results in extensive 
destruction of the tissues that compose the intestinal wall. The 
glandular structures disappear, while the bases of the ulcers become 
extensively infiltrated and tumefied, thus originating the indurated 
masses that can often be distinguished through the walls of the abdomen 
during the later stages of emaciation. By the formation of cicatricial 
tissues, and by contraction of the inflamed structures, the intestine 
becomes narrowed to a degree that will scarcely suffer the passage of 
the finger through its tube. Perforation of the peritoneal investment 
of the intestine may take place through extension of the ulcerative 
process. Death, preceded by collapse, then speedily occurs. In malig- 
nant forms of the disease the mucous membrane of the intestine may 
rapidly perish and be thrown off in sloughing masses of a gangrenous 
character. Fibrinous exudations upon the internal surface of the 
intestine produce a roughened appearance in which the prominences 
are indicative of infiltration in the connective tissue beneath the 
surface. 

The spleen is small, firm, and dry, unless the patient has also suf- 
fered from malarial infection. The bladder is frequently inflamed, 
and, in chronic dysentery, becomes the seat of extensive ulceration. 
The liver usually presents slight modifications, except in cases of 
abscess formed by purulent infection of the organ. Similar abscesses 
are sometimes found in the lungs. 

Etiology. Dysentery is a disease that prevails more frequently 
and with greater severity as the equatorial regions of the earth are 
approached. It is more prevalent in warm weather than in cold, 
hence the fact that it becomes endemic in warm climates alone. In 
the temperate zone it prevails during the latter part of summer and in 
the autumn, disappearing during the cold weather of winter. Variable 
temperatures, such as prevail during the autumn months, favor sudden 
refrigeration of the body after copious perspiration, hence the frequent 
occurrence of the disease during seasons of the year when cold nights 
succeed hot days. 

Slow starvation, errors of diet, unwholesome food, impure water that 
has been contaminated with the products of putrefaction and fecal 
excrement, are common causes of dysentery. Similar infection of the 
atmosphere upon battle-fields covered with the decaying bodies of men 
and animals, and in the vicinity of filthy privies, must be numbered 
among the causes of the disease. 



DYSENTERY, 



109 




Amoeba eoli. (Hallopeatj.) 



There is no satisfactory evidence of the direct transmission of con- 
tagion from person to person. It is probable that the infective agent 
is indirectly transmitted through the faecal discharges of the patient 
which find their way into the water-supply by which the food and 
drink of other individuals are contaminated. 

The nature of the infective agent by which dysentery is propagated 
is not yet fully understood, though it is undoubtedly of parasitic origin. 
Various microorganisms have been discovered in the inflamed tissues of 
the intestine. In the tropics and 

elsewhere, various forms of FlG - ? 3 - 

amoeba have been identified in 
the colon and in the hepatic or 
pulmonary abscesses that some- 
times complicate the disease, and 
they have been considered as its 
cause. Various micrococci, min- 
ute bacilli, and spirilla, differing 
slightly from the comma bacilla 
of cholera, are found in the in- 
flamed tissues of the intestine. 
They are found in the glandular 
epithelium, in the connective 
tissues, and in the lymphatic 
vessels and glands. It is not 
possible to distinguish any one . 
of these different parasites as the sole cause of dysentery ; it is probable 
that they all contribute to the evolution of the disease, and perhaps 
the predominance of different specific microorganisms may be the 
efficient cause of corresponding variations in the type of the resulting 
disorder. 

Treatment. The hygienic treatment of dysentery requires atten- 
tion to the diet and water-supply of the community. Wholesome food, 
the avoidance of intemperance in eating and drinking, protection of 
the body from sudden chill, especially when in a state of perspiration, 
are the most important items for control. The utmost cleanliness 
should be required in person and habitation. Thorough ventilation 
and drainage, with efficient removal or disinfection of all faecal dis- 
charges are imperative. The initial diarrhoea by which dysentery is 
often introduced, may be treated by evacuation of the bowels with 
castor oil or with a few grains of calomel, followed by a saline cathartic, 
such as Rochelle salts, citrate of magnesia, Seidlitz powders, or Epsom 
salts, to be followed every four hours with a grain of opium and ten 
grains of bismuth, until the diarrhoea has ceased. Repeated doses of a 
saline cathartic given till copious watery stools are evacuated often 
yield an excellent result. The recumbent position, with a flannel 
bandage around the abdomen will greatly expedite recovery. By 
many physicians the use of purgatives in this stage of the disease is 
considered unnecessary, unless there be evidence of intestinal repletion. 

When the symptoms of dysentery are fully developed, the indications 
for treatment are: 1, the relief of pain and tenesmus ; 2, the arrest of 



110 PARASITIC AND INFECTIVE DISEASES. 

inflammation. With these objects in view, the entire abdomen should 
be covered with a large poultice, which may be rendered more efficient 
by sprinkling its surface with laudanum and chloroform. Hypodermic 
injections of morphine and atropine may be repeated as often as re- 
quired for the relief of pain. If poultices cannot be tolerated on 
account of their weight or inconvenience, they may be replaced by 
flannels wrung out of warm water and covered with an oiled silk 
bandage that encircles the whole body. Tenesmus may be relieved by 
the employment of opiated suppositories, or by injection into the 
rectum of an ounce of thin starch, containing thirty or forty drops of 
the tincture of opium. 

By the English physicians in India, ipecacuanha is extolled as the 
most efficient remedy that can be employed in the treatment of acute 
dysentery. The powder should be given in doses of twenty or thirty 
grains, made up into five-grain pills or wrapped in a wafer. A grain 
of opium may be given at the same time, and the patient should remain 
in the recumbent position, taking no drink for an hour after receiving 
the dose. At the expiration of four or five hours, fifteen to twenty 
grains may be again administered, and for three or four successive 
days the remedy should be continued, in doses of ten grains three or 
four times a day. Vomiting rarely follows, though nausea is not 
uncommon. Copious bilious stools generally follow the treatment, 
with great relief from pain, abundant perspiration, and cessation of the 
characteristic intestinal disorder. It is said, however, that cases com- 
plicated with malarial infection are less amenable to this mode of 
treatment than the simple forms of dysentery. 

Astringent remedies, either vegetable or mineral, are of very little 
value. The mineral acids are especially useful during the period of 
convalescence, when they may be given in combination with tonic doses 
of quinine. 

Local treatment of the rectum by the cautious use of warm water 
slowly injected into the bowel, affords considerable relief by cleansing 
the inflamed and ulcerated surfaces. The topical application of cocaine 
in solution to the anal orifice is also of service. 

Chronic dysentery is often benefited by change of climate and im- 
provement of the hygienic surroundings of the patient. The diet must 
contain nothing of an irritating character ; milk, koumiss, broths, raw 
eggs, oysters, the pulp of raw beef. sago. rice, and flour that has been 
thoroughly cooked and boiled with milk, may be allowed. Bismuth 
in large doses (one to four drachms) is beneficial. Nitrate of silver, 
sulphate of copper, and other astringent remedies have been recom- 
mended. Ten drops of liquor ferri pernitratis may be given in cold 
water every three or four hours. But local treatment of the colon 
with medicated injections affords the best results. The bowel should 
be washed out every day with a large injection of tepid water, which 
must be followed by a medicated injection. This should consist of 
nitrate of silver dissolved in water in the proportion of five grains to 
each pint of the liquid. By some physicians it has been used in a 
higher degree of concentration, as much as thirty or forty grains being 
dissolved in each pint. These injections occasion considerable pain 



ACTINOMYCOSIS. 



Ill 



for a short time, but they are generally followed by relief of all the 
symptoms. Ulcers that can be reached through the anus may be 
cauterized with nitric acid, followed by a strong solution of an alkaline 
salt, as recommended in the treatment of internal hemorrhoids. Obsti- 
nate cases - have sometimes been cured by daily injections of undiluted 
brandy. This occasions a burning sensation, soon followed by relief 
of all the symptoms. A cure has been known to follow the daily 
administration of a half-pint of castor oil, swallowed at a single dose. 
Ten drops of the compound tincture of iodine, diluted with half a pint 
of water, may be given before each meal with advantage. Opiates in 
all forms should be avoided as far as possible, on account of their 
unfavorable effect upon the digestive functions. 



DISEASES CAUSED BY VEGETABLE PARASITES. 



CHAPTER V 



ACTINOMYCOSIS. 



This disease is produced by the fungus actinomyces, a vegetable 
parasite that sometimes finds access to the tissues of cattle. The 
parasite consists of minute granular masses of a sulphur-yellow color, 
surrounded by radiating crowns of club-shaped mycelia, giving to 
the fully formed growth an appearance not unlike that of the flower 
of an aster (Fig. 74). These little bodies are from the tenth to the 
fortieth of an inch in diameter. 
By their presence in the tissues 
they excite inflammation, which 
results in the formation of ab- 
scesses that enlarge and tend 
to discharge their contents ex- 
ternally. The tumors thus 
formed are most frequently 
found in the soft parts between 
the lower jaw and the integu- 
ment. 

The parasitic organisms hav- 
ing entered the tissues through 
the cavities of carious teeth, the 
tumor thus formed enlarges 
downward, and extends into 
the neck, leaving a track of 
cicatricial tissue. Similar tu- 
mors may form outside of the 

upper jaw, and may thus invade the cavities of the face and head, bur- 
rowing along the base of the skull and along the vertebral column 




Actinomyces (from a case of disease in man). 
(Payne.) 



112 



PARASITIC AXD INFECTIVE DISEASES. 



Suppuration finally becomes established, and in the pus may be dis- 
covered yellow masses made up of the mycelia of the fungus. Some- 
times tumors may form within the lungs, which then become adherent 
to the walls of the chest. The same process of abscess formation is 
set up, with a final discharge of pus through the chest wall. From the 
alimentary canal also, by a similar process, the peritoneal cavity and 
the adjacent organs may be invaded, with subsequent perforation of the 
abdominal wall. The suppurative processes thus inaugurated are 
chronic in their character, and usually terminate fatally, unless the 
tumors or abscesses are so situated as to permit of removal by surgical 
aid. 

The parasite is seldom communicated from animal tissues to the 
human subject. It must pass through an intermediate stage of de- 
velopment in vegetable tissues before it can invade the body of man. 
For this reason infection usually occurs through the chewing of straw, 
after the manner of horse jockeys and stablemen, who thus become 
infected directly from the vegetable kingdom, instead of deriving the 
disease from the animals with whom they associate. 



CHAPTEE VI. 

MALIGNANT PUSTULE— ANTHRAX. 

Etiology. Anthrax is an acute, infective disease, caused by inocu- 
lation with virus derived from certain of the lower animals, in which it 
occurs as a primary affection. Herbivorous animals are most subject, 



Fig. 75. 




Bacilli anthracis. 



X 500. a. Rods, 
cultivation. 



b. Filaments in different stages obtained by 
Spores. (Bristowe.) 



by reason of the fact that the contagion depends upon the presence of 
a bacillus (Fig. 75) (Bacillus anthracis) that flourishes in the soil of 
certain localities, and attaches itself to the grass and herbage upon which 



MALIGNANT PUSTULE — ANTHRAX. 113 

such animals are pastured. Finding entrance into the respiratory and 
alimentary passages of horses, cattle, sheep, and other graminivorous 
animals, the spores of the parasite penetrate all the tissues and per- 
vade every part of the body. The infected animals soon die, and every 
portion of their decomposing bodies may become a vehicle for the dis- 
semination of the pathogenic organisms that have caused their death. 
The contagion adheres to everything with which the body has been in 
contact. Stalls and barns, in which the diseased animals have been 
kept, thus become centres of contagion for the infection of healthy 
animals. The earth where a dead body has fallen becomes filled with 
contagious matter, and even after burial, the soil is infected through 
the agency of earthworms that bring to the surface particles of mould 
in which the poisonous bacilli thrive and produce their spores. In this 
way the disease may become widely diffused, prevailing as an epizootic 
among the flocks and herds of entire communities. Since every portion 
of the diseased animal is infected, human beings who are brought in 
contact with such animals or their products, are excessively liable to 
contract the disease. Farmers, shepherds, butchers, dealers in hides, 
horns, and hair, may thus contract malignant pustule by handling such 
articles when they have been derived from infected animals ; the 
smallest cut, scratch or puncture may admit the virus. It is said to 
have been conveyed by flies, which have introduced the poison into the 
skin of the victim. 

Anthrax affects animals as a general disease, but when man is inocu- 
lated with virus containing the pathogenic bacillus or its spores, the 
disease appears at first as a local affection upon the surface of the skin. 
At the point where inoculation takes place is produced a lesion called 
malignant pustule. When the virus is received through the intestinal 
mucous membrane the local affection is called intestinal mycosis. It is 
not impossible that infection may sometimes occur through the respiratory 
passages. 

Symptoms. Malignant pustule. The period of incubation after 
inoculation continues for about three days. On the fourth day a vesi- 
cle appears at the point of inoculation which rapidly enlarges, ulcerates, 
and presents a livid color, with considerable swelling of the surround- 
ing tissues. The lymphatic vessels that proceed from the affected part 
become inflamed, and the neighboring lymphatic glands enlarge. 
There is high fever and great nervous prostration. Death occurs after 
three or four days, preceded by great exhaustion, cyanosis, and fall of 
temperature before the fatal termination. In cases of recovery the con- 
stitutional symptoms are less urgent, and the disease is more strictly 
localized in its manifestations. The symptoms of local inflammation 
gradually subside, cicatrization takes place, and the patient becomes 
convalescent. 

Intestinal mycosis. In this form of the disease the virus finds admis- 
sion to the body through the gastro-intestinal mucous membranes : 
cutaneous inflammation is absent, and the external symptoms of malig- 
nant pustule do not appear, unless there has been coincident inocula- 
tion through the skin. In cases of simple intestinal inflammation 
there is no period of incubation ; the symptoms of disease follow almost 

8 



114 PARASITIC AND INFECTIVE DISEASES. 

immediately after the invasion of the tissues : sometimes local swellings 
or vesicles appear upon the skin as a consequence of the constitutional 
infection. The general symptoms consist of fever, pain in the limbs. 
hack, and head, great nervous prostration, nausea, vomiting, colic, 
diarrhcea. dyspnoea, petechial spots upon the skin, hemorrhages from 
the orifices of the body, stupor, coma, muscular spasm, collapse, and 
death. 

In certain cases the local lesions involve the pharynx, producing 
swelling, ulceration, and gangrene of the pharyngeal tissues. The 
general symptoms are identical with those that accompany the inl 
nal form of the disease. 

Pathological Anatomy. The blood is dark and disorganized : 
the spleen is enlarged, and contains numerous bacilli : the lymphatic 
glands are also enl _ the sei >ns membranes present an hemorrha- 

gic appearance. In cases that have been characterized before death by 
dyspnoea and other pulmonary symptoms the pleural cavities contain a 
reddish, serous fluid : the mediastinum is infiltrated with a similar 
liquid, and the bronchial glands are greatly enlarged. The intestinal 
mucous membranes are swollen and turgid, with hemorrhagic infiltra- 
tions. Sometimes ulceration and gangrenous patches are visible. The 
liver and kidneys, as well as the other organs of the body, contain the 
pathogenic bacilli in great numbers. 

DIAGNOSIS. Malignant pustule must be distinguished from furun- 
cles, carbuncles, and the nodules of glanders. The fact of previous 
inoculation and the history of the case should assist the diagnosis. 

A. furuncle presents a distinct core, and •< exhibit the lymph- 

atic invasion that characterizes malignant pustule. The swelling of the 
anthrax pustule is more diffuse and dark in color, and is followed by 
gangrene of the tissue- instea I of the simple suppuration and speedy 
recovery that attend the evolution of a boil. 

The formation of a carbuncle usually takes place upon the covered 
portions of th and the slough is very slowly developed : while 

the pustule of anthrax generally appears upon the uncovered portions of 
the body, and prog: »£ 3 with great rapidity. 

The nodule* of glanders are usually developed upon the lymphatic 
vessels, are several in number, and are connected together by the in- 
flamed and prominent lymphatics. The characteristic nasal ulceration 
and discharge is absent in cases of anthrax. 

The pharyngeal and intestinal forms of the disease are less 
recognition, in consequence of the late development of external mani- 
festations, if they occur. The history of the patient, the probabil: 
infection by the use of milk or flesh from infected animals, may serve to 
in. The rapid and fatal course of the disease and the dis- 
covery of the characteristic bacillus. . will suffice to establish 
the diagri' sis. 

Pb If ree< _ _ te early stage, and if subjected to 

active treatment, the mortality in r malignant pustule need not 

r cent, or even less. After constitutional infection has 

taken place through delay in the recognition of the disease, the nior- 



TYPHOID FEVER. 115 

tality reaches forty or fifty per cent. The intestinal form of the dis- 
ease is almost hopeless. 

Treatment. The treatment of malignant pustule requires destruc- 
tion of the local lesion by the actual cautery, or by the use of the most 
powerful caustics. Having thus destroyed the focus from which gene- 
ral infection would take place, ordinary surgical dressings should be 
employed, and the strength of the patient must be sustained with 
tonics, moderate doses of alcohol, and nutritious food, until recovery is 
complete. 



CHAPTEK 711. 

TYPHOID FEVEK. 

Typhoid Fever is a general disease that is caused by infection of 
the body with a specific microorganism, the bacillus typhosus. It is a 
disease that is encountered in all parts of the world. It is especially 
common as an endemic fever in large cities, and among crowded popu- 
lations who neglect ordinary hygienic precautions. 

Symptoms. Period of incubation. The period of incubation is 
variable, sometimes not exceeding two or three days ; usually occupying 
one or two weeks, it may be sometimes prolonged for a month or more. 

The period of invasion is characterized by lassitude, pain in the back 
and muscles, loss of appetite, dizziness, insomnia, and a tendency to 
epistaxis. Occasionally the onset of the fever is abruptly introduced 
by chill ; occasionally, however, the catarrhal condition of the throat 
and digestive organs constitutes the first symptomatic disturbance. A 
continuous fever sets in, with a temperature that rises every evening 
above the temperature of the preceding evening until the latter part of 
the first week, when the fastigium is reached. During this period of 
development there is headache, wakefulness, vertigo, coated tongue, 
diarrhoea, enlargement of the spleen, and a moderate degree of bronchial 
catarrh. 

The fastigium of the fever occupies the second week and the greater 
part of the third. At the commencement of the second week there is 
an eruption of rose spots upon the abdominal surface. These disappear 
under the finger, but reappear as soon as pressure is removed. The 
occurrence of this eruption is sometimes attended by a brief remission 
of the fever, and the amelioration of nervous symptoms. The eruption 
continues until the subsidence of the fever. During the stage of con- 
tinued fever the tongue becomes dry, sorcles accumulate upon the teeth 
and occupy the nasal passages and pharynx. The tongue is protruded 
with difficulty, and is sometimes tremulous. There is considerable 
deafness, the expression of the countenance is dull and heavy, and there 
is mild delirium, usually more pronounced at night ; or the patient 
sinks into a condition of apathy and stupor. The stools are liquid, 
fetid, and of an ochreous character. After the tenth day they contain 



116 PARASITIC AND INFECTIVE DISEASES. 

the bacilli. Sometimes diarrhcea is absent, but the stools when voided 
present the characteristic color. Vomiting seldom occurs, but there is 
usually some degree of tenderness over the epigastrium and in the 
right iliac fossa, where gurgling may be distinguished under the pressure 
of the fingers. The intestines are often distended with gas. by reason 
of the paralysis of their walls. The urine is scanty, high colored, and 
frequently contains albumin, but the amount of urea is diminished. 
Sometimes there is vesical paralysis, requiring the use of the catheter. 
The spleen is enlarged, the pulse becomes soft and dicrotic, especially 
in severe cases, "When the respiratory organs are seriously affected the 
movements of respiration are accelerated. 

During the latter portion of the third week, or at some time in the 
course of the fourth week, defervescence commences. The temperature 
gradually falls. The expression of the patient exhibits more intelli- 
gence, the skin becomes moist, the urine increases in quantity, some- 
times there is a critical discharge of urates, or there may be a moderate 
hemorrhage that is followed by improvement in the condition of the 
patient. The daily oscillations of temperature become exaggerated, 
gradually approaching the normal standard during the morning hours, 
though in many cases rising at evening to the highest point observed 
during the fastigium. 

The period of convalescence is tedious when the preceding fever has 
been severe. In mild cases recovery is comparatively rapid. All the 
functions of the body are imperfectly performed, there is great emacia- 
tion and anaemia, requiring a long course of reparation. Digestion is 
performed with difficulty, and food frequently produces nausea and 
vomiting if pressed too rapidly upon the stomach. The functions of 
the brain are for a long time enfeebled. Memory and intellectual 
activity are slowly recovered. Sometimes insanity, various neuroses, 
tuberculosis, heart disease, and other visceral disorders date from this 
period. 

Certain symptoms of the fever require particular mention. The 
temperature in typical cases rises by successive stages each day. during 
the first week, until it has reached 104° or 105° F., at night. The 
maximum temperature is generally observed in the afternoon or evening : 
the minimum temperature occurs about seven or eight o'clock in the 
morning ; at each time the temperature is half a degree or a degree 
lower than on the preceding evening. During the fastigium the 
daily oscillations seldom exceed a degree and a half, and the evening 
temperature remains quite uniform. During the period of decline more 
extensive oscillations are frequently observed, especially when compli- 
cations exist. Xotable departures from the typical course of the 
temperature are not uncommon. Sometimes the disease runs its course 
without elevation of temperature : sometimes a high temperature is 
developed as early as the second day ; sometimes the maximum tem- 
perature is registered in the morning; in certain cases there is a rapid 
fall of the temperature at the commencement of the period of decline. 
A definite relation between the severity of the disease and the elevation 
of the temperature is usually observed. High figures indicate great 
danger. Recovery rarely occurs when the temperature exceeds 105° or 



TYPHOID FEVER. 117 

106° F. When the morning remissions are well marked and prolonged, 
the fever is usually light. A continuous high temperature is an 
unfavorable symptom. The persistence of such temperatures during 
the fourth week indicates the presence of complicating diseases. Death 
is frequently preceded by extraordinary elevation of the temperature, 
or by its equally sudden and unusual depression. During the period 
of convalescence a sudden rise of temperature indicates some inter- 
current complication. A relapse of the fever is indicated by a gradual 
and uninterrupted elevation. In malarious localities the periods of 
invasion and of defervescence are frequently characterized by an inter- 
mittent type of fever. 

The condition of the pulse affords valuable information regarding the 
patient. It is more rapid in female patients than in male. During the 
fastigium, in ordinary cases of fever, the pulse should not exceed 104 
beats, or 120 for a female patient. When the number of beats exceeds 
120 there is danger of cardiac failure. A weak and rapid pulse is 
usually developed during the later stages of a dangerous fever ; but 
sometimes the opposite extreme is observed in such cases, and the pulse 
sinks far below the normal figure. A dicrotic pulse is almost always 
present in typhoid fever. Irregularity of the pulse is an alarming 
symptom. 

The urine is diminished and high colored ; it sometimes contains 
blood and a small quantity of albumin, without indicating any special 
danger, but when albumin is present in large quantities it indicates 
serious disorganization of the kidneys. The amount of urea is reduced, 
but is increased at the commencement of convalescence. Uric acid is 
increased, excepting in fatal cases. The chlorides and other inorganic 
constituents of the urine are diminished during the fastigium. The 
total aggregate of solids contained in the urine is somewhat greater 
than in health, hence the rapid emaciation of the patient. Numerous 
imperfectly oxidized products of disintegration appear in the urine, and 
doubtless serve by their presence in the blood and in the tissues to 
aggravate the symptoms of the disease. 

So numerous and so frequent are the complications that accompany 
the course of typhoid fever that nearly seventy-five per cent, of the 
mortality from typhoid fever must be ascribed to complicating causes. 
During the period of invasion copious bleeding from the nose indicates 
a hemorrhagic tendency. Various forms of sore-throat, thrush, and 
gastric disorders may exist as complications. Pneumonia also some- 
times coexists with the early stage of the disease. This is probably 
dependent upon the cooperation of the two forms of contagion. Occa- 
sionally serous pleurisy is observed during the early stages of typhoid 
fever. 

During the fastigium g astro-intestinal inflammation, erosion* ulcera- 
tion, and perforation may occur. Peritonitis may also develop, either 
as a consequence of perforation or by reason of an extension of the 
inflammatory processes from the interior of the stomach and intestines. 
It is sometimes caused by rupture of the gall-bladder, or by the evacua- 
tion of an abscess in the spleen, or elsewhere. Intestinal "hemorrhage 
is one of the most common of the abdominal complications belonging to 



118 PARASITIC AXD INFECTIVE DISEASES. 

this period. It is more frequent among females than among; males, and 
is usually observed during the course of the second or third week. 
Sometimes there is a copious discharge of blood from the anus ; in other 
cases the intestinal canal may be filled with blood without any external 
evacuation. Slight hemorrhages are not dangerous, and are sometimes 
followed by amelioration of the symptoms of the fever. Laryngeal 
erosions and ulcerations exist in about twenty per cent, of the fatal 
cases ; they frequently escape observation before death, but sometimes 
they produce laryngeal oedema, perichondritis, and necrosis of the 
cartilages. Catarrhal bronchitis is almost always present during the 
fastigium, and is usually overlooked, unless it acquires considerable 
severity. Hypostatic pneumonia commonly exists in severe cases, when 
the patient lies continually upon the back. Lobar pneumonia may occur 
at any stage of the disease. It is frequently insidious, and progresses 
without marked symptoms, assuming an adynamic form like that of 
senile pneumonia. Pleurisy rarely occurs. Cerebral symptoms are 
frequently observed, and are largely dependent upon the presence of 
typhoid bacilli in the brain. Sometimes the symptoms of pneumonia 
or of acute meningitis are manifested. Occasionally the symptoms 
assume the form of a low, querulous form of paranoia. Sometimes 
suicidal impulses exist. In the majority of cases that exhibit symptoms 
of insanity, a previous predisposition in that direction may be dis- 
covered. 

During the period of convalescence various gastro-intestinal disorders 
are frequently experienced ; these are usually of an inflammatory 
character, and are dependent upon previous lesions of the adenoid tissue 
along the course of the alimentary canal. Sometimes jaundice and 
biliary disorders are produced by the migration of various species of 
bacteria from the intestine into the biliary passages. An exhausted 
and anaemic condition of the brain frequently persists for a long period 
of time, and is occasionally folloAved by permanent mental weakness or 
derangement. Among children a form of aphasia sometimes exists for 
two or three weeks, and then disappears completely. Various dis- 
turbances of the functions of the peripheral nerves are sometimes 
manifested during the period of convalescence ; these are generally 
dependent upon neuritis. Ulceration of the cornea, which sometimes 
originates during the course of the fever, may prove intractable, per- 
sisting during the period of convalescence, and resulting in complete 
destruction of the eye. The ear also frequently becomes involved by 
suppuration that extends along the Eustachian tube from the nose into 
the middle ear, often producing perforation of the tympanum and loss 
of hearing. Caries of the petrous portion of the temporal bone rarely 
occurs. Degeneration of the cardiac muscle produces great weakness 
of the heart and a feeble circulation of the blood. Sudden death during 
the course of typhoid fever is frequently dependent upon this cause. It 
is especially frequent on waking in the morning, if the patient has 
been left without sufficient nourishment during the night. The blood- 
vessels are frequently attacked by inflammation of their walls. In this 
way an artery may become obliterated, or a thrombus may obstruct 
the veins. The muscles frequently undergo a special form of degenera- 



TYPHOID FEVER. 119 

tion, and are sometimes ruptured as a consequence of the weakness that 
is thus produced. In certain cases the bones become the seat of inflam- 
matory action, accompanied by pain and deformity, or by the gradual 
development of circumscribed periostitis and osteitis. The joints also 
become swelled and painful, as if attacked by rheumatism. Some- 
times pyemic suppuration involves the articulations. During the 
period of convalescence, various glandular structures may be invaded 
by inflammation. The parotid gland, the thyroid gland, the ovaries, 
and the testicles are sometimes thus disorganized. 

In addition to the lesions above described, the existence of typhoid 
fever frequently seems to favor the invasion of the organism by various 
other infective agents, so that pneumonia, erysipelas, diphtheria, gan- 
grene, and other infective diseases, either appear during the course of 
the fever, or follow its decline. The ordinary bacterium coli frequently 
improves this opportunity to invade the biliary passages and other 
organs of the body, in which it produces inflammatory symptoms. 

The evolution of typhoid fever is subject to many varieties of form, 
which are probably dependent upon the relative variations of the bac- 
terial contagion in different cases. In the ambulatory form of typhoid 
fever the patient does not feel sufficiently ill to remain in bed ; he 
appears debilitated and pale ; complains of headache and of pain in his 
limbs ; his sleep is restless ; sometimes there is a mild diarrhoea ; the 
spleen is always enlarged ; the pulse is accelerated, and a few rose spots 
may generally be discovered. Recovery is reached in the course of 
four or five weeks. These cases, though mild, are not devoid of danger, 
since ulceration, hemorrhage, and perforation of the intestine may lead 
to a fatal result. 

Abortive forms of the fever sometimes occur. The symptoms develop 
suddenly in the midst of health. Upon the second day the temperature 
reaches 103° or 104° F. Gastric symptoms and diarrhoea are promi- 
nent ; but during the second week there is sudden defervescence, accom- 
panied by copious perspiration, or by an abundant discharge of urine. 
Sometimes hemorrhage occurs from the nose or from the uterus. Re- 
covery is the rule ; but when death occurs from some complication, the 
characteristic intestinal lesions are discovered. 

The adynamic form of typhoid fever is characterized by intense 
prostration. The pulse is w r eak and exceedingly compressible. The 
intellect is greatly obscured, diarrhoea is excessive, and hemorrhage 
frequently occurs. In some cases there is an intense fever, accompa- 
nied by violent delirium and hallucinations. Subsultus tendinum is 
commonly observed, and sometimes there are convulsions. 

A hemorrhagic tendency is not uncommonly associated with the 
severe and prostrating forms of the fever. Blood may also escape into 
the subcutaneous areolar tissue, or from any of the mucous membranes 
of the body. 

Typhoid fever may occur at any age, even before birth. When it 
occurs among young children, delirium is very common. Gastrointes- 
tinal disturbances are accompanied by a painful distention of the abdo- 
men, almost successive of peritonitis. The intestinal lesions are less 
severe than in adults, but the mesenteric ganglia are greatly enlarged. 



120 PARASITIC AXD INFECTIVE DISEASES. 

The disease is sometimes accompanied or followed by paralytic symp- 
toms and aphasia. Other infective diseases may occur as compli- 
cations. 

When typhoid fever attacks elderly people it commences insidiously, 
with a low grade of fever, and a frequent absence of severe abdominal 
symptoms and rose spots. The characteristic feature of the disease is 
the great prostration that it produces. Respiratory disorders frequently 
occur as complications. 

The invasion of the pharynx, larynx, heart, lungs, pleura, and 
kidneys by an inflammatory process is not unfrequently observed, and 
is accompanied by the characteristic symptoms of such inflammations. 

A splenic form of typhoid fever has been observed. It is character- 
ized by a recurrent type of fever, and by the absence of intestinal dis- 
orders. The spleen is sometimes enlarged, and its capsule exhibits the 
appearances of localized peritonitis. In other cases the spleen is greatly 
enlarged by the occurrence of hemorrhage within its substance. The 
fever continues for six or seven weeks : then, after an intermission of 
one or two weeks, the fever again recurs. In still another form of the 
disease the symptoms of ordinary relapsing fever are closely imitated, 
and the disease can only be distinguished by the absence of spirilla 
from the blood. 

In certain obscure forms of the fever the symptoms of general septi- 
caemia are manifested during life, but the autopsy reveals the presence 
of typhoid bacilli in various organs of the body. 

The concurrence of pneumonia and typhoid fever has been already 
noted. Scarlatina, variola, and measles may also concur with typhoid 
fever. In malarious countries miasmatic contagion and the typhoid 
bacillus may simultaneously invade the patient, producing that form of 
fever which has been termed typho-malarial fever. In certain cases 
the typhoid type is predominant, while in others the malarial features 
characterize the fever. The symptoms of both diseases are intimately 
associated : usually the commencement and conclusion of the fever are 
characterized by a malarial physiognomy, while the fastigium presents 
the more characteristic features of typhoid fever. The lesions of typhoid 
are frequently less conspicuous than in uncomplicated cases, and the 
liver exhibits the enlargement and discoloration that are produced in 
malarial infection. Sudden death, intestinal hemorrhage, and perfora- 
tion are not uncommon incidents. Quinine exerts comparatively little 
influence upon the course of the fever. 

A peculiar form of typhoid fever has been recently described in the 
east of Europe under the name of canine typhoid. It has also been 
observed in other parts of the world. The period of invasion occupies 
from one to three days, during which the patient complains of general 
discomfort and constipation. This is followed by a rapid development 
of the fever, which almost immediately reaches a temperature of 104° 
F. After the third day diarrhoea, epistaxis. and intestinal hemorrhage 
occur. Fever subsides at the end of the first week, though diarrhoea 
and enlargement of the spleen continue for a longer period, and the 
stools contain typhoid bacilli. The pulse is always slow, sometimes 
being depressed as low as fifty beats. It has been observed that this 



TYPHOID FEVER. 121 

form of fever only occurs among patients who have been previously 
victimized by malaria. 

The duration of typhoid fever is closely associated with the severity 
of its symptoms. The average duration is about twenty-five days, but 
in severe cases it may continue for a much longer period. 

The mortality of the disease has always been very considerable. 
According to Murchison, who founded his statistics upon 27,951 cases, 
the mortality was 17.45 per cent. Jaccoud found a mortality of 19.23 
per cent, among 80,149 cases ; but since that date later statistics, which 
include numerous mild cases that were formerly excluded, and which 
also exhibit the results of improved methods of treatment, yield a more 
favorable percentage. 

The conclusion of an attack of typhoid fever is sometimes followed 
by a relapse. This usually occurs from four to ten days after apparent 
recovery, and is characterized by many of the symptoms of the original 
invasion. In the majority of cases the period of relapse is shorter and 
less severe than the original attack, but there are exceptions to this 
rule. The cause of such relapses is supposed to consist in a re-infection 
of the system by the liberation of bacilli which had been imprisoned 
within the organs of the body. In this respect the relapse of typhoid 
fever resembles the corresponding recurrence of relapsing fever. It 
is supposed that in such cases the elements of the tissues have not 
acquired that tolerance of the typhoid poison which is usually only 
reached after a prolonged exposure to its influence. Laboratory experi- 
ments indicate that the protection of mice against the contagion of 
typhoid fever can only be obtained by numerous successive inoculations 
which exert an influence that is comparable to the effects of acclimati- 
zation — that is, a continuous invasion of the system by small quantities 
of the contagion. 

Pathological Anatomy. In each organ of the body the morbid 
process that underlies typhoid fever is characterized by the intrusion 
of the specific contagion. Its rapid multiplication and its reaction with 
the white corpuscles and phagocytic cells of the tissues lead to dis- 
turbances of the circulation, degeneration of the parenchyma, and death, 
or reparative action and final recovery. During these active perver- 
sions of normal function, the organism is liable to invasion by other 
infective agents, by which secondary processes maybe set up — e.g., 
suppurative inflammation, pneumonia, etc. During the process of con- 
valescence the dead and enfeebled cells of the tissues are removed by 
the agency of phagocytes and other excretory structures, while the sur- 
viving tissues proliferate and replace the missing elements, so that in 
many instances the general health is greatly improved after an attack 
of typhoid fever. Sometimes, however, the process of repair is imper- 
fect, and connective tissue takes the place of highly organized paren- 
chymatous structures. In this way various structural diseases of the 
nervous, vascular, renal, and hepatic organs, may be initiated. 

It is in the small intestine that pathological changes are first devel- 
oped. The neighborhood of the ileo-ca3cal valve is the favorite seat of 
the morbid processes. During the first week of the fever the mucous 
membrane becomes infiltrated with typhoid bacilli, and the phenomena 



122 PARASITIC AND INFECTIVE DISEASES. 

of catarrhal inflammation are developed. The follicles of Lieberkilhn 
and the patches of Peyer become swelled and elevated. After the 
sixth da}^, in severe cases, the patches become still more swelled, indu- 
rated, and reddened. The lymphatic vessels are dilated and filled with 
white corpuscles. Numerous typhoid bacilli may be discovered in colo- 
nies, or diffused among the tissue cells. The lymph vessels in the 
deeper portions of the patch contain numerous bacilli, and sometimes 
they may be discovered in the walls and in the lumen of the blood- 
vessels themselves. The obstruction of the circulation that is thus 
effected soon leads to fatty degeneration of the tissue cells and of the 
leucocytes. In mild cases the process does not advance to ulceration, 
but the products of degeneration are absorbed and removed by the sur- 
viving cells. In severe cases ulceration occurs about the tenth or 
twelfth day of the fever. The degenerated tissues break down and are 
discharged into the intestine. The minute follicular ulcerations are 
exceedingly dangerous on account of their depth and tendency to per- 
foration of the intestinal wall. During the third week of the fever the 
necrosed surface of the ulcerated patches is throw T n off, leaving a clean, 
granular ulceration, which is slowly repaired by a tardy process of cica- 
trization. Fortunately, the intestine rarely undergoes constriction as a 
result of this process. Sometimes the scar becomes darkly pigmented. 
In certain cases the above-mentioned lesions are very insignificant, or 
may be wholly absent. This is the case in the early stage of foetal 
growth, but in the embryo of seven or eight months, the intestinal folli- 
cles, the mesenteric glands, and the spleen, have been found in a state 
of disease. 

The mesenteric glands begin to enlarge at the very commencement 
of the fever; they exhibit a condition of hyperemia, and become infil- 
trated w T ith bacilli and phagocytes in a manner very similar to what is 
observed in the patches of Peyer. During the subsidence of the disease 
the mesenteric glands undergo fatty degeneration of their cellular ele- 
ments, and sometimes actual suppuration takes place. 

In the adenoid tissues of the gastric mucous membrane, pathological 
changes occur that closely resemble the corresponding processes in the 
patches of Peyer. The epithelium of the peptic glands undergoes fatty 
degeneration. Similar changes are observed in the adenoid tissues of 
the pharynx, tonsils, fauces, and base of the tongue. 

The spleen begins to enlarge during the first week of the fever, and 
by the end of the second week it is frequently two or three times its 
normal size. Sometimes the organ is ruptured by excessive swelling. 
Typhoid bacilli are numerous in its substance during the first half of 
the disease. 

The liver is rarely increased in size, but its color is pale or ashy- 
gray. The bile is scanty, thin, and light-colored. A moderate degree 
of fatty degeneration that is proportioned to the intensity of the disease 
may be observed in the hepatic cells. Numerous bacilli are accumulated 
in the portal vein and in its capillary ramifications. The biliary pas- 
sages are also invaded by typhoid bacilli and by other microorganisms, 
producing, sometimes, catarrhal inflammation, ulceration, or even per- 
foration of the gall-bladder. 



TYPHOID FEVER. 123 

The pancreas and the salivary glands are swelled at an early stage 
of the disease, and their glandular epithelium undergoes granular de- 
generation. 

The bronchi exhibit a condition of catarrhal inflammation. All 
forms of inflammation may occur in the lungs. The different forms of 
pleurisy may be also excited by the typhoid bacillus, or by other secondary 
microorganisms. In like manner the adenoid tissues of the larynx 
are usually invaded, and inflammation, suppuration, and necrosis may 
subsequently attack the various tissues of the organ. 

In the nervous system, leucocytic infiltration is frequently observed 
in the perivascular sheaths, and around the nerve cells which are some- 
times loaded w T ith pigment. The process of repair sometimes results 
in a redundant formation of connective tissue. Multiple sclerosis of 
the brain or spinal cord may thus find its starting-point in the conse- 
quences of typhoid fever. Sometimes neuritis has a similar origin in 
the inflammatory tendencies of the fever. 

The kidneys are generally more or less involved. In severe cases 
bacilli may be discovered in the urine, and a diffuse nephritis is developed. 
The urine contains albumin and granular or colloid casts. The muscles 
are dry, and with the aid of a microscope a condition of waxy degene- 
ration may be discovered in some of the fibres, while others exhibit 
fatty degeneration. A similar condition is often present in the muscu- 
lar structures of the heart. The nutrient vessels of the organ fre- 
quently exhibit a condition of endarteritis, followed by consequent 
degeneration of the muscular structure, long after the termination of the 
fever. A similar condition is common in the walls of the bloodvessels in 
the neighborhood of the intestine and other organs where the specific 
bacilli are particularly numerous. 

The blood contains very few bacilli, but its red corpuscles are 
diminished in number, and their haemoglobin is greatly reduced in 
amount. The white blood-corpuscles are increased in number during 
the early stages of the disease, but at a later period they migrate into 
the tissues in such numbers that the blood itself contains less than the 
normal quantity. 

The marrow of the bones undergoes changes similar to those that 
are observed in the spleen. The presence of typhoid bacilli some- 
times causes circumscribed inflammations and necrosis that may persist 
for a long time after the conclusion of the fever. Occasionally the 
joints undergo corresponding changes. 

Furuncles and subcutaneous abscesses are not uncommon during the 
period of convalescence. The bacilli may be discovered in the pus of 
such abscesses for many months after the fever. Sometimes gangrene 
occurs as a result of vascular inflammation and obstruction. The 
parotid glands and the testicles are sometimes inflamed, and may 
undergo suppuration. 

Etiology. Typhoid fever was formerly ascribed to the introduction 
of putrid substances into the blood. By certain pathologists it was 
supposed to be the consequence of auto-infection with morbid products 
of tissue change that were accumulated within the organism. In 1880, 
Eberth described the bacillus typhosus and announced its causative 



124 PARASITIC AND INFECTIVE DISEASES. 

relation to the phenomena of typhoid fever. The bacillus which he 
discovered varies in its form, according to the character of the medium 
in which it grows and multiplies. It is from one-quarter to one-third 
of the diameter of the red blood-corpuscle, and its transverse diameter 
is about one-third of its length (Fig. 76). It presents near its central 

portion, a clear space which is supposed to 

F,G - 76 - indicate a partial degeneration of its sub- 

s stance. The organism exhibits a power of 

*&» j „, ^ motion that is dependent upon the existence 

" """ /* of vibratile cilia. It may be easily cultivated 

^a? °"v jf> # . in broth, milk, urine, gelatin, potatoes, and 

# ^^ other media of the laboratory. It can be 

. / pS made to flourish in a vacuum, or in an atmos- 

g **y>j> phere of hydrogen. So readily does it adapt 

Typhoid bacilli with spores, itself to variable conditions and localities that 

(Hallopkau.) its universal prevalence and persistence are 

easily explained. It is still an open question 

whether the bacillus produces spores, or whether the minute spheres 

which have been considered, as spores are anything more than a mass of 

degenerated protoplasm, similar to what forms the clear space in the 

middle portion of the bacillus. 

The typhoid bacillus is capable of supporting for a brief period a tem- 
perature of 194° F., but if exposed to moist heat at a temperature of 
140° F. for twenty minutes, its vitality is destroyed. 

Enclosed in a block of ice at a temperature considerably below the 
freezing-point, the microorganism remains alive for many months, but 
if the water in which it is contained is alternately frozen and thawed 
five times a day, the bacillus is completely destroyed within three 
days. 

The chemical rays of solar light rapidly destroy the vitality of the 
typhoid bacillus. The organism flourishes best in the absence of sun- 
light. 

It has been shown that the action of the gastric juice upon the 
typhoid bacillus depends upon the presence of hydrochloric acid. The 
normal degree of acidity is insufficient to destroy the bacillus, though 
its vigor and power of proliferation are somewhat diminished. In an 
aqueous solution of hydrochloric acid that is three times as strong as 
ordinary gastric juice, the bacilli are destroyed only after the expiration 
of three hours. Hence it is apparent that under ordinary conditions 
the fluids of the stomach are incapable of protecting the organism 
against the invasion of typhoid contagion. 

From old cultures of the typhoid bacillus has been extracted a 
ptomaine to which has been given the name typho-toxine. This, how- 
ever, does not represent all of the poisonous products of the bacillus. 
It has been shown that the soluble products of the microbe sterilize 
gelatin upon which it has been cultivated, so that fresh crops of the 
bacillus can no longer be propagated upon that soil. It has also been 
shown that these soluble products when injected into the bodies of mice, 
produce immunity against the disease. It is probable that they have 
the same effect upon the tissues of human beings. The investigation of 



TYPHOID FEVER. 125 

these toxalbuinins will doubtless be attended with much that is inter- 
esting in the matter of pathology and prophylaxis. 

Examination of the bodies of patients who have died of typhoid fever 
indicates the almost uniform presence of the typhoid bacillus in the 
liver, spleen, mesenteric glands, and patches of Peyer. It is found less 
frequently in the other organs of the body, and very rarely in the 
blood. Its presence in the different organs is supposed to explain 
various local phenomena of the disease. When the fever has run 
through a long course before the death of the patient, other micro- 
organisms that somewhat resemble the typhoid bacillus are frequently 
found in the tissues. Sometimes they may be identified with the ordi- 
nary bacterium coli, but they often resemble common modifications of 
the genuine typhoid bacillus. 

During life the bacillus is rarely found in the blood. It must be 
sought in the organs of the body. It may, however, be found in the 
rose spots at the time of their eruption. It has been asserted that these 
papillary phenomena are due to embolic obstruction by the accumula- 
tion of bacilli in certain vascular tufts within the skin. The microbe 
can be readily discovered in the feces, in the urine, and in the sputa 
from the lungs. After the termination of typhoid fever the bacilli 
sometimes remain for a long time in certain portions of the body, and 
preserve their vitality for many months. Under such circumstances 
the microorganism appears to assume pyogenic virulence. It is present 
in the abscesses and other suppurative lesions that sometimes follow the 
course of the fever. 

The lower animals do not become spontaneously infected with the 
contagion of typhoid fever. Many experiments have shown the impos- 
sibility of exciting the disease by feeding them with the discharges of 
typhoid patients, but it has been recently shown that by the injection 
of virulent cultures into the duodenum or into the peritoneal cavity of 
guinea-pigs and white mice, it is possible to produce symptoms of fever, 
diarrhoea, swelling of the patches of Peyer, mesenteric glands, and 
spleen, followed by the death of the animal, and the discovery of the 
specific bacilli in its tissues. It has also been ascertained that if the virus 
be attenuated by its culture at a temperature of 107°-113° F., a fatal 
result rarely occurs ; and by inoculating white mice with the soluble 
products of bacterial growth, they may be protected against infection 
with virulent cultures. 

The contagion of typhoid fever is principally diffused through the 
medium of fecal matter. It is also contained in albuminous urine, and 
in the blood of intestinal hemorrhages from typhoid patients. It is 
sometimes found in the sputa and in pus that is formed in abscesses 
after the fever. The bacillus is most abundant in the intestinal dis- 
charges during the period of ulceration, especially between the tenth 
and seventeenth days of the fever. In ordinary cases the specific 
microorganism cannot be found after the twenty-second day, unless 
relapses of the fever are experienced. 

After the discharge of typhoid feces the specific microbe remains 
alive and virulent for a considerable period of time. Desiccation does 
not destroy its vitality ; consequently dried feces form an excellent 



126 PARASITIC AND INFECTIVE DISEASES. 

vehicle by which it may be mingled with the dust and diffused through 
the atmosphere, finding its way into open reservoirs of water, and 
washed by the rain into the interstices of the soil. Clothing that has 
been soiled may become a means of conveying contagion, and it may 
lie dormant in the dust and dirt of a deserted habitation for months or 
years. In the accumulations of privies, the germs of fever may pre- 
serve their vitality for an indefinite period, exercising no deleterious 
effect upon the neighborhood until they are liberated by the agitation to 
which the fecal mass is subjected when the privy vault is emptied. In 
this way the atmosphere over a vault may become charged with viru- 
lent microbes, exciting fever where it had been for a considerable time 
unknown. 

The contagion of typhoid fever is very frequently transmitted through 
the medium of drinking-water. Many cases are recorded in which the 
contamination of a particular well or rivulet has been followed by a 
formidable outbreak of fever among the people who drew their water 
supply from that particular well or stream. Sometimes the water source 
becomes contaminated by the filtration of rain-water from some dung- 
hill which had been made the receptacle for typhoid discharges. The 
deposit of manure that has been mixed with typhoid feces upon fields 
from which the subterranean water is collected for the supply of drink- 
ing water, is followed by no deleterious results until the expiration of a 
month after the first rainfall ; the typhoid microbes sink with the rain 
into the soil, and find their way with the subterranean water into the 
wells and reservoirs which derive their supply from that particular 
locality. In this way the occurrence of typhoid fever may sometimes 
appear to be dependent upon meteorological causes. 

Laboratory experiments have shown that typhoid bacilli, when mixed 
with healthy feces, preserve their vitality at ordinary temperatures, 
provided the fecal matter be kept slightly alkaline. In acid media the 
bacilli are destroyed in two or three days, but they remain active for 
three or four months when mixed with comparatively solid fecal matters. 
From these experiments it is evident that the specific microbe of typhoid 
fever cannot be easily destroyed by the ordinary conditions to which it 
is exposed. In privy vaults, dunghills, dust, and soil, it undoubtedly 
preserves its vitality for a period that is much greater than any that has 
been measured under the artificial circumstances of laboratory culture. 

The determination of the presence of typhoid bacilli in drinking- 
water is not always easy, since ordinary water is not a favorable medium 
for their growth. Under such circumstances their form and virulence 
may undergo considerable modification, and the ordinary bacteria that 
vegetate in water appear to exercise an unfavorable influence upon their 
development. A number of bacterial organisms exist in water which 
closely resemble the typhoid bacillus, but careful observation of the 
form, mode of motion, and culture of these different organisms suffices 
to determine their nature. It has been shown that when typhoid 
bacilli are introduced into impure water that swarms with ordinary 
bacteria, their number is rapidly diminished during the first twenty days, 
but that after that time the few survivors remain apparently acclima- 
tized and capable of rapidly propagating the species when introduced 



TYPHOID FEVER. 127 

into more favorable media. This very considerable reduction of num- 
bers might easily lead an incautious observer to infer their entire dis- 
appearance. 

Though it is true that the typhoid bacillus cannot easily maintain 
itself in moving water, it finds a congenial habitat in the mud 
that accumulates in reservoirs and flowing streams. When contami- 
nated water is placed in a bottle that contains a small quantity of mud, 
the bacilli disappear from the water after the expiration of two months, 
but they still remain numerous and vigorous in the deposit at the 
bottom of the flask. 

It has been claimed by many observers that the use of foul water 
favors the invasion of the body by the contagion which otherwise would 
have been successfully resisted by the organism. While this hypothe- 
sis is not without a certain degree of plausibility, no facts are yet 
recorded for its demonstration. There is no evidence to show that 
typhoid bacilli can penetrate the tissues and there remain latent until 
wakened to activity by irrigation with dirty water. All the facts of 
observation indicate that whatever may be said against the use of impure 
water, typhoid fever will never be excited by its action alone. 

Milk has been frequently accused of transporting the contagion of 
typhoid fever. Obviously it is possible for the liquid to be contami- 
nated with dust or other impurities that contain the desiccated germs of 
the disease. But in the majority of cases it has been shown that milk 
has been rendered deleterious by mixture with water from a well or 
other source that contains the specific bacilli. In this way vegetables 
may be sometimes contaminated by immersion in unhealthy water. 
Lettuce, celery, and other greens that have been sprinkled with water 
from a contaminated source might thus convey the contagion of the dis- 
ease. It is certain that the majority of articles that are used as food 
afford excellent media for the cultivation of the typhoid bacillus. 

It is very doubtful whether typhoid contagion can enter the human 
body through abrasions or wounds upon the cutaneous surface. The 
infective bacilli may find their way through the delicate membranes 
that line the air-cells of the lungs, but in the majority of cases the port 
of entry is through the mucous membrane of the intestinal canal. Not 
only do the facts that have been observed regarding the effects of un- 
wholesome drinking-water, but also the condition of the intestinal 
mucous membrane, crowded with masses of bacilli at the commence- 
ment of the disease, serve to establish this conclusion. 

The typhoid bacillus may be transported by the air, but it is almost 
impossible for it to be inspired in quantity sufficient to produce infec- 
tion ; it is, however, probable that bacilli thus transported into the 
mouth and pharynx may be swallowed, and may thus reach the intes- 
tine, where they readily multiply. 

The typhoid bacillus can be conveyed through the blood of the mother 
into the body of the foetus. It has often been found in the liver and 
spleen of the aborted embryo. The foetus sometimes preserves its 
vitality, and is not thrown off when the mother suffers from an attack 
of typhoid fever. It is probable that in such cases immunity is acquired 
by the offspring. 



128 PARASITIC AND INFECTIVE DISEASES. 

Typhoid fever is most frequently experienced in youth and early 
adult life. It seldom occurs after the fortieth year ; about one-fourth 
of the fatal cases occur between the twentieth and twenty-fifth years of 
life. The disease is more frequent among men than among women, 
but its fatality is greater among the female sex. Recent immigrants 
into an infected locality are more susceptible than those who have 
become acclimatized by long residence ; hence it is more commonly 
observed among young country people who flock into the large cities in 
search of employment. 

The occurrence of typhoid fever is favored by those conditions of 
life and by those occupations that occasion fatigue, insufficient or un- 
wholesome alimentation, and a general depression of vitality. Exposure 
to cold, pregnancy, and slight departures from the normal condition of 
health operate as predisposing causes of the disease. Laboratory ex- 
periments have shown that fowls which have been inoculated with the 
virus of chicken-cholera do not succumb to the disease unless they are 
chilled by prolonged immersion in cold water. Refrigeration favors the 
development of the virus, and the symptoms of cholera soon appear. 
It has also been shown that when pigeons are inoculated with the 
virus of anthrax, they do not become infected unless deprived of suffi- 
cient food. In this way it is easy to explain the manner in w T hich cold 
and hunger favor the propagation and development of various infective 
diseases. 

Prognosis. No case of typhoid fever can exist without danger to 
the patient. The disease is always dangerous among elderly people, 
among the victims of obesity, alcohol, and physical exhaustion of every 
description. During pregnancy it is dangerous, both in itself, and by 
reason of the tendency to abortion. The perils of the disease are greatly 
increased by every form of cardiac and vascular weakness and disorder. 
It is more dangerous to women than to men, especially when they suffer 
from chlorosis and congenital imperfections of the vascular organs. 
Neurotic patients constitute unfavorable subjects for the fever, since they 
are predisposed to cerebral and nervous disorders which develop during 
the course of the disease, and may persist after its convalescence. All 
forms of unusual nervous depression and disorder afford an unfavorable 
basis for the prognosis. Excessive temperature, and a sudden defer- 
vescence that is not determined by hemorrhage or by therapeutic meas- 
ures, are most alarming symptoms. When the course of the fever is 
marked by considerable oscillations of temperature, the prognosis is 
more favorable than it is when the temperature is continuously and 
uniformly elevated. The persistence of the fever beyond the end of 
the third week is an unfavorable symptom when it cannot be ascribed 
to a relapse. Secondary infections also increase the gravity of the 
situation. A pulse that exceeds 120 beats, especially if it be feeble and 
irregular, indicates great danger. Recovery is almost unknown if the 
number of beats reach 150 per minute. A slow pulse is no sign of 
amelioration, since it is usually excited by great nervous prostration, 
by myocarditis, or by intestinal hemorrhage. Copious discharge of 
urine is usually a favorable symptom. 

Diagnosis. Typical cases of typhoid fever can be easily recognized 






TYPHOID FEVER. 129 

when their symptoms are fully developed. Abortive forms of the fever 
are with difficulty distinguished from g astro-intestinal disturbances that 
are accompanied by a febrile movement ; these, however, are usually 
accompanied by vomiting, diarrhoea, and colic. The spleen does not 
become enlarged, nor does the fever continue longer than a week or 
ten days. 

Typhus fever is distinguished by its rapid onset, and by the char- 
acter of the eruption, which is livid, and does not disappear on 
pressure. 

The typhoid condition which sometimes accompanies severe forms 
of remittent fever cannot be easily distinguished from typho-malarial 
fever, except by microscopical examination of the blood for the hsema- 
tozoon of malaria. The stools should also be examined, in order to 
determine the absence of typhoid bacilli which are present in the mixed 
form of the disease. 

The fever that accompanies the secondary stage of syphilis appears 
simultaneously with the roseolous eruption , instead of preceding it by 
a week. 

Herpetic fever sometimes may be mistaken for typhoid fever until 
the appearance of the characteristic eruption enlightens the diagnosis. 
Inflammations of the kidneys that are accompanied by fever can be 
distinguished from typhoid fever by the thermometric curve, by the 
absence of rose spots, enlargement of the spleen, and diarrhoea. 

In obscure and irregular forms of fever the diagnosis is sometimes 
impossible unless aided by the discovery of typhoid bacilli. 

Those forms of pneumonia accompanied by delirium or stupor may 
be differentiated from real typhoid fever by physical examination of the 
lungs. When typhoid fever actually coexists with pneumonia, the fact 
can only be determined by the persistence of its characteristic symptoms 
after the subsidence of pulmonary inflammation. 

When pleurisy co-exists with typhoid fever, it presents its ordinary 
phenomena, but the combined disease is characterized by unusual inten- 
sity of fever, with great prostration, headache, and wakefulness. The 
fever is continued, and does not present the remissions that characterize 
severe forms of tubercular pleurisy. Among nervous women the inva- 
sion of typhoid fever is sometimes characterized by all the symptoms of 
tubercular meningitis. In such cases, however, ophthalmoscopic exami- 
nation discovers no tubercles in the choroid ; and after a few days the 
characteristic differences between the two forms of fever become appa- 
rent. Similar confusion is not uncommon in the case of children when 
attacked with typhoid fever. When meningitis occurs as a complica- 
tion, it is often difficult to differentiate it from tubercular meningitis if 
there be no diarrhoea or rose spots apparent. 

Acute miliary tuberculosis frequently resembles typhoid fever when 
accompanied by diarrhoea and by roseola. But the oscillations of tem- 
perature are more irregular, and there is a greater degree of dyspnoea. 
The discovery of tubercular bacilli in the sputa is a decisive event. 

Cerebrospinal meningitis is accompanied by intense headache and 
pain in the spine. The head is drawn backward, diarrhoea is usually 
absent, the tongue remains moist, and rose spots do not appear. 

9 



130 PARASITIC AND INFECTIVE DISEASES. 

Ulct foe endocarditis em ifferentiated by careful exami- 

nation of the hearr. and by the discovery of embolic symptoms. 

Influenza sometimes resembles typhoid fever, but its rapid course 
and the predominance of bronchial symptoms serve to distinguish the 
disease. 

Trieh&M ables typhoid fever during its acute s: 

but it may be differentiated by the existence of intense pain and ten- 
derness in the muscles, and by the occurrence of oedema about the face 
and eyeli Is. 

Thr n of gl iers may be. in certain stages of the disease, 

mistaken foi fcy] hoid fever. 

Septt inflammations are often accompanied by symptoms that 
resemble typhoid fever, but the remittent character of the febrile 
movement, and the development of abscesses serve as differential indi- 
cations. 

In like manner acute infective :s'-: :-"\wtlitis can be readily mistaken 
for typhoid fever, if the osseous lesions are overlooked. 

Acute mania presents delirious symptoms which sometimes lea", tc 
confusion with the delirium of typhoid fever, but the mental derange- 
ment is unaccompanied by the febrile movement and other symptoms 
that characterize the typh se. 

Prophylaxis. The most important prophylactic measure ag 
the propagation of typhoid fever consists in the sufficient supply of pure 
drinking-water for public use. Xext to this must be considered the 
suppression of privy vaults, and the substitution of a method by which 
fecal matters can be completely and immediately removed from the 
vicinity of every habitation. If pure drinking-water cannot be obtained, 
the supply should be sterilized by boiling, or by filtration through un- 
glazed porcelain, or fine-grained stone. Apartments that have been 
occupied by typhoid fever patients should be disinfected by washing all 
the wood-work with a 1 : 1 lution of corrosive sublimate : after 

this disinfection it should be repainted, and the walls should be white- 
washed. Bedding and clothing, carpets, and other draperies should 
be exposed to hot air in a disinfecting stove constructed for the pur- 
When typhoid fever attacks a regiment, or other body of men 
that can ilized, their transportation to an uninfected locality is 

the best means of arresting the progress of the epidemic. 

The care of typhoid patients demands the greatest attention to per- 
sonal cleanliness on the part of the sufferer and his attendant.-. Fre- 
quent og with warm water and soap, and the use of a 1 : 1000 
solur: rrosive sublimate as a disinfectant for the hands, will 
e the dang a >n. Soiled clothing should be 
placed in a basin or tub of water until it can be subjected to a boiling 
temperature for at least half an hour. All the excreta of the patient — 
sputa, feces, urine, etc. — should be sterilized as soon as voided by the 
addition of ordinary milk of lime, containing 20 per cent, of hydrated 
calcium. Of this liquid, two parts by measure are sufficient to sterilize 
one hundred parts of typhoid excreta, and its action is much more ener- 
getic and prompt than that of other more costly and dangerous disin- 
fectants. 



TYPHOID FEVER. 131 

Treatment. Since typhoid fever is caused by the invasion of the 
body by a parasitic contagion, and by the intoxication of the tissues 
with poisons that are produced through the activity of this parasite, a 
genuine curative treatment should consist either in the destruction of 
the contagion, or in the fortification of the tissues against the products 
of its growth. Since, however, we at present possess nothing capable 
of fulfilling these indications, it becomes necessary to proceed indirectly 
against the effects of the disease. Various methods have been adopted 
in past times with the hope of combating the fever, but the majority of 
these processes now possess only an historical interest. It becomes 
necessary either to adopt an expectant method, which consists in allow- 
ing the patient to drift, aided only by inert medication and by more or 
less judicious nursing, or to resort to measures which consist chiefly in 
the employment of baths for the reduction of temperature, and the 
cautious supply of food in such form as will best promote nutrition in 
an enfeebled subject. Two principal methods for the application of 
these measures are in vogue : the method of Bouchard, which finds 
favor in Paris, and the method of Brand, which is universally employed 
by the Germans. According to the Parisian system, the patient is 
bathed eight times each day ; the bath in which he is placed must be 
about 3° lower than the rectal temperature ; the water is then gradu- 
ally cooled down to a temperature of 86° F. In this way the body is 
refrigerated without any disagreeable shock to the system. Every 
third day the patient receives half an ounce of sulphate of magnesia. 
During the first four days of the treatment seven grains of calomel are 
given each day, in divided doses. During the period of intestinal 
disorder a drachm of naphthol and half a drachm of the salicylate of 
bismuth are given in divided doses ; and every morning and evening 
the bowels are washed out with warm water containing naphthol. Qui- 
nine is also administered when the temperature cannot be reduced by 
the baths. During the first two weeks it should be given in doses of 
thirty grains ; during the third week the dose may be reduced to twenty 
grains ; and during the fourth and fifth weeks it need not exceed fifteen 
grains. These doses should be repeated only after intervals of three 
days, if the temperature reaches a great elevation. The diet must con- 
sist of broths, gruels, and lemonade. If delirium be excessive, opiates 
may be administered. 

The method of Brand consists in the application of cold, chiefly 
through the employment of baths, and in the careful nourishment of 
the patient. By the early employment of these measures the intestinal 
lesions are largely prevented, and the consequences of general infection 
are reduced to a minimum. For the complete success of the treatment 
it must be inaugurated at the commencement of the fever, so as to 
anticipate the consequences of general infection. The only contra-indi- 
cations to the cold-water treatment are derived from the condition of 
the heart, and from the occurrence of intestinal perforation or perito- 
nitis. Weak and diseased hearts require the method of Bouchard, 
which is also preferable in cases of old persons, or very young children. 
The occurrence of pneumonia at an advanced period of the disease, and 
other conditions indicated by exhaustion and a tendency to syncope, 



132 PARASITIC AND INFECTIVE DISEASES. 

which usually present themselves during the later stages of the fever, 
render the method of gradual refrigeration preferable to sudden immer- 
sion in the cold bath of Brand. 

It has been shown that repeated refrigerations are followed by pro- 
gressively increasing intervals during which the temperature remains 
depressed, consequently an early commencement and frequent repeti- 
tion of cold baths prevents the development of a high temperature as 
the fever rises toward its fastigium. For the successful employment 
of baths a sufficient number of attendants is indispensable ; the tub 
should be placed upon wheels so that it can be readily conveyed to the 
bedside. The temperature of the water should be 68° F., and its quan- 
tity must be sufficient to cover the patient to the chin as he lies 
extended in the tub : the duration of the bath should be from ten to 
fifteen minutes, and it should be repeated whenever the rectal tempera- 
ture rises above 103°. It is advisable to sponge the face and chest 
with cold water before entering the bath, in order to prevent the dis- 
agreeable sensation that might otherwise be caused by sudden immer- 
sion. While lying in the bath, the head should be wrapped in a 
towel, upon which cold water may be poured for two or three minutes 
at the commencement, during the middle, and at the close of the 
immersion. The surface of the body and of the extremities should be 
thoroughly rubbed with the hand during the whole period of the bath. 
As soon as shivering commences the patient should be removed from 
the water, wiped dry, and placed in bed. A bag of warm water may 
be placed at the feet, and at the end of half an hour a cup of beef-tea. 
broth, milk, gruel, or coffee, may be given before the commencement 
of the quiet sleep that usually follows each bath. If the temperature 
be not sufficiently depressed, and the patient remains restless and 
burning with fever, cold compresses or a coil through which cold water 
continually circulates, should be applied over the abdomen. In severe 
cases characterized by an extraordinary temperature-, the bath may be 
cooled down to 60° F., and the patient may be allowed to shiver con- 
siderably before he is removed from the water. It may be necessary 
sometimes to renew the baths every two hours. 

During the subsidence of the fever the patient should be bathed less 
frequently, but this method of treatment should not be abruptly ter- 
minated. A cold bath at night is exceedingly grateful so long as the 
temperature continues to rise during the latter part of the day. 

During the height of the fever the diet should consist of liquids 
administered after each bath. When the fever begins to subside, soup 
may take the place of beef-tea. Thin chocolate, a little wine, and 
three or four soft-boiled eggs may be allowed each day. Milk is 
always useful when it can be digested, but the appearance of white 
particles of curd in the stools indicates that it is being given in excess. 

During the period of convalescence the diet list may be gradually 
enlarged, but with caution, since the feeble state of the digestive 
organs renders it impossible to dispose of anything but the most easily 
digested articles of food. A small quantity of the breast of chicken, 
broiled fish, calves' brains, game, and tenderloin steaks, may be 
allowed in moderation. Fat meat cannot be digested. After the 



TYPHOID FEVER. 133 

temperature has ceased to rise for three or four days, bread and 
vegetables may be allowed. 

During the course of the fever cold drinks may be given in abund- 
ance ; the patient may be allowed his choice among them all. When 
there is considerable prostration, strong wine or whiskey may be used 
with great advantage. 

The utmost cleanliness must be preserved about the patient and his 
bedding. Free ventilation of the apartment is necessary. Clothing 
and the excretions of the body should be disinfected in the manner 
previously described. The mouth and throat must be carefully cleansed 
several times a day with a weak solution of permanganate of potas- 
sium. 

When typhoid fever attacks elderly people the prognosis is exceed- 
ingly grave, since above the age of forty-five the mortality is not less 
than 40 per cent. Such patients do not support cold baths, but 
must be treated with warm baths gradually refrigerated. The same 
treatment should be preferred whenever there is a tendency to collapse 
and an abnormal depression of temperature. Alcoholic stimulants are 
then useful. 

Thoracic complications that are not attended by symptoms of heart 
failure may be subjected to the cold bath. Opiates may also be given 
in small doses to such patients for the relief of harassing cough. 
Excessive diarrhoea may be frequently relieved by rectal injections 
containing thirty drops of laudanum. Excessive distention of the 
abdomen is best relieved by cold external applications, and by the 
internal use of antiseptics, according to the method of Bouchard. 
Cardiac weakness is relieved by frequent warm baths, accompanied by 
friction of the skin and the administration of cardiac stimulants. 

Intestinal hemorrhage during the first week of the fever is an indica- 
tion for cold bathing, but when it occurs during the later stages of the 
fever, the bath must be forbidden. Cold applications should then be 
applied over the abdomen, and the diet should be restricted to cold 
milk or iced beef-tea. In cases of dangerous and alarming hemorrhage 
great benefit is often derived from the hypodermic injection of a steril- 
ized solution of chloride of sodium in distilled water (7 : 1000). The 
symptoms of perforation and of peritonitis call for perfect repose, 
maintained by cold applications to the abdomen, and large doses of 
opium by the mouth, or morphine hypodermically. 

In all cases of typhoid fever it is desirable to promote the action of 
the kidneys, in order to remove as completely as possible the products 
of disintegration of tissue and the soluble poisons that are produced by 
bacterial evolution. For this reason antipyrine is objectionable, since 
it hinders the processes of elimination. 

The adoption of the methods of treatment described above have 
resulted in a remarkable reduction of the mortality from typhoid fever. 
Formerly the mortality in European hospitals reached 25 per cent., 
but the method of Bouchard has reduced that mortality in the hospitals 
of Paris to 10 per cent. ; and by the method of Brand in private prac- 
tice it is reduced to 2 per cent. ; in civil hospitals it stands at 6.7 per 
cent., while in military hospitals it hovers between 9 and 10 per cent., 



13-i PARASITIC AXD INFECTIVE DISEASES. 

and even under the unfavorable circumstances of actual warfare it does 
not exceed 11.4 per cent. 

From the foregoing description it is evident that the treatment of 
typhoid fever by the hydropathic method is attended with great labor. 
It is consequently most efficient in hospitals, where sufficient attendance 
and nursing can be obtained. In private practice it is, in the majority 
of cases, impossible to secure the efficient application of such measures. 
The treatment with cold water must also be commenced early in the 
course of the disease in order to accomplish the most beneficial results. 
Elderly people, very young children, and very delicately organized 
patients cannot be subjected to such energetic measures as are indicated 
for young and vigorous adults. For these reasons the full adoption of 
the complete hydropathic method is often impracticable. In many 
cases, however, warm baths, gradually cooled down to 70° F., can be 
administered at intervals during the day. And if the patient cannot 
be treated to the full bath, much benefit may be derived from frequent 
sponging of the body, and from the application of cold cloths over the 
abdomen. If possible, the use of coils, through which cold water is 
made to circulate, should be encouraged, and in every practicable way 
the attempt should be made to diminish the temperature by external 
refrigerant applications. Antipyrine and other powerful febrifuge 
remedies should be used with caution, never longer than two or three 
days at a time, since they hinder the processes of elimination and 
retard the course of defervescence. Complications must be met with 
appropriate measures as they present themselves. In all cases that 
cannot be subjected to hydropathic treatment, judicious nursing, liquid 
food, consisting chiefly of gruel, broth, and milk, should form the basis 
of treatment. A mild mercurial course is appropriate during the early 
days of the fever ; calomel in small doses, or mercury and chalk, may 
be given for two or three days : naphthol or naphthaline, in five grain 
doses every four hours, if there be fermentation and gaseous distention 
of the intestines ; salicylate of bismuth, in ten grain doses every four 
hours, is also useful when the diarrhoea is excessive. Frequent stools, 
indicative of irritation in the lower bowel, may be moderated by a 
rectal injection containing twenty drops of laudanum conveyed through 
a rectal tube to a considerable distance above the internal sphincter. 
During the earliest stage of the fever, when there is great heat and 
thirst, cold drinks and effervescing powders are often very grateful to 
the patient, but they should not be urged if there be manifested a dis- 
inclination to their use. Cold tea and cold water slightly acidulated 
are often more agreeable than any other beverage. Ten drops of dilute 
phosphoric acid in a wineglass of cold water may be administered 
every three or four hours. Restlessness and wakefulness at night, 
especially when they occur during the later course of the fever, call 
for an increased amount of nourishment and stimulants. If these be 
insufficient, sleep may be frequently procured by the administration of 
thirty grains of sulphonal ; antipyrine often affords a similar good result 
with children ; opiates and chloral should generally be avoided on 
account of their depressing influence upon the heart. "When it becomes 
necessary to administer opiates, alcoholic stimulants, beef-tea, and egg- 



INFLUENZA — GEIPPE. 135 

nog should also be given, since death sometimes occurs from heart 
failure, intensified by opiates if administered without cardiac stimulants. 
Whenever the heart exhibits signs of weakness, indicated by a rapid 
and compressible pulse, strychnine should be administered in doses of 
•g 1 ^- of a grain every three or four hours. Caffeine, one grain every 
two or three hours ; camphor, one grain every two hours ; or musk, 
one grain every two or three hours, will be found useful in such cases. 
Severe inflammation of the stomach and small intestine, indicated by a 
dry, red tongue, is frequently benefited by the administration of nitrate 
of silver (argent, nitrat., pulv. opii, aa gr. J every six hours). If 
these symptoms are associated with considerable meteorism, oil of 
turpentine, in doses of five or ten drops in an emulsion, may be 
administered every two hours, and turpentine liniment should be 
applied over the abdominal surface. Care should be taken to with- 
draw the remedy if any symptoms of vesical irritation appear, and it 
should not be administered if the urine contains albumin or blood. 
In malarial localities, quinine may be administered during the first 
three or four days of the fever, and during the period of convalescence, 
but it is of little use during the fastigium, except as a means of 
depressing the temperature by the occasional administration of fifteen 
grain doses, if other more agreeable remedies seem to be contra- 
indicated. 



CHAPTER VIII. 

INFLUENZA— GRIPPE. 

Influenza is an epidemic, infective, catarrhal fever, characterized by 
intensity of the catarrhal symptoms, by great prostration of the nervous 
system, and by a tardy convalescence that is sometimes accompanied by 
serious nervous disorders. It differs from ordinary catarrhal fevers and 
coryzas by its greater severity and liability to complications, by its 
pandemic diffusion, and by its dependence upon a transmissible cause. 

Symptoms. The course of influenza is marked by three stages : 
1. The stage of invasion. 2. The catarrhal stage. 3. Decline and 
convalescence. The period of incubation is of exceedingly variable 
duration, lasting from a few hours only to a number of days or weeks. 

The period of invasion is marked by a feeling of general uneasiness 
followed by a chill of greater or less severity, loss of appetite, nausea, 
great nervous prostration, exhaustion, supra-orbital headache, and pain 
in the spinal region. These symptoms resemble the initial symptoms of 
many acute diseases. The characteristic feature of the period of inva- 
sion is intense prostration, out of all proportion with the severity of the 
actual symptoms. Sometimes there is epistaxis and a general condition 
of congestion of the mucous membranes. Sometimes the period of 
invasion appears to be absent. It is usually very brief, rarely con- 
tinuing longer than a single day. 



136 PARASITIC AND INFECTIVE DISEASES. 

Catarrhal period. The full development of influenza is characterized 
by violent coryza involving the maxillary and frontal sinuses, the 
lachrymal ducts, and the ocular conjunctivae. Extending downward, 
it speedily involves the Eustachian tube, the pharynx, the larynx, the 
trachea, the bronchi, and the gastro-intestinal mucous membranes. 
Headache continues with a sensation of tension and fulness about the 
vertex. The nervous system becomes more profoundly affected. In 
this fact lies one of the principal marks of difference between influenza 
and ordinary catarrhal fevers. There is a feeling of precordial dis- 
tress, muscular tremor, vertigo, and disturbance of the special senses, 
such as transient impairment of vision, tinnitus aurium, and sometimes 
earache ; the senses of taste and smell are, of course, diminished by the 
coryzal condition of the mucous surfaces. Sometimes there is an ex- 
altation of cutaneous sensibility, with severe neuralgia and articular 
pains like those of rheumatism.. Sleep is uneasy and imperfect ; there 
may be mild delirium, and there is great depression of spirits. The 
countenance of the patient exhibits an appearance of suffering and 
intellectual dulness, like that of a person who has experienced a pro- 
tracted illness. 

The febrile movement is marked by great irregularity ; fever is some- 
times absent ; generally, however, it assumes a remittent type, with 
evening exacerbations ; but may be distinctly intermittent, resembling 
a quotidian or a double tertian fever. Sometimes there are numerous 
exacerbations during the course of the day. Sometimes the tempera- 
ture is higher in the morning than in the evening. It rarely reaches 
the height that is common in tvphoid fever. Usuallv it varies between 
100° and 102° F., occasionally reaching 104° or 10>)°. 

Incessant laryngeal irritation provokes frequent paroxysms of cough, 
by which the headache is greatly increased. As the disease progresses 
expectoration is established, and the sputa may be occasionally streaked 
with blood. Respiration is at first slightly accelerated, and is some- 
times associated with evidences of laryngeal inflammation. As the 
catarrhal inflammation invades the bronchi, the rales of bronchitis 
become audible throughout the chest. Unless complicated by pneu- 
monia, the percussion note remains normal. 

The tongue becomes invested with a thick, yellowish fur ; the mouth 
is pasty ; everything tastes badly ; thirst is excessive ; appetite is lack- 
ing; there is nausea, and sometimes vomiting of mucus or of biliary 
matters. Pressure upon the epigastric region produces pain, and there 
is a feeling of tension and pain in the hypochondriac regions. In 
some cases there is intestinal colic followed by diarrhoea, in which the 
passages contain mucus, bile, and occasionally blood. Not unfrequently, 
however, the early stage of the disease is characterized by obstinate con- 
stipation that aggravates the headache. 

In many cases the course of the disease is marked by the predomi- 
nance of symptoms involving certain organs of the body. Three prin- 
cipal forms of influenza thus become prominent : 

1. The encephalic form, characterized by an exaggeration of the 
ordinary nervous phenomena of the disease. In such cases the coryzal 
symptoms are excessive, and the ordinary headache may be accompanied 



INFLUENZA — GRIPPE. 137 

by intense neuralgia, delirium, convulsions, or even apoplectiform 
attacks. The mind sometimes becomes alienated, and the patient may 
exhibit the symptoms of insanity, sometimes characterized by a suicidal 
tendency. Among children there is a tendency to coma, which among 
old people may be accompanied by paralysis and apoplectiform phe- 
nomena. 

2. In the thoracic form of influenza the mucous membranes of the 
respiratory passages are the seat of the most prominent symptoms. 
The inflammation is catarrhal in its character ; pneumonia, pleurisy, 
and cardiac or pericardial inflammations must be regarded as complica- 
tions when they occur. 

3. The abdominal form of influenza is less frequent than the other 
forms of the disease ; yet in certain epidemics it is frequently observed. 
In this form the respiratory organs may present little, if any, evidence 
of disease, while gastro-intestinal inflammation may be exceedingly 
severe. The general symptoms of this variety closely resemble those 
that are furnished by ordinary gastro-intestinal inflammation, but they 
are attended by a greater degree of exhaustion and nervous prostration 
than is observed in ordinary enteritis. The severity of the abdominal 
symptoms and their epidemic course has not unfrequently suggested 
reminiscences of dysentery and cholera ; hence the term " winter 
cholera" that has been sometimes applied to this form of influenza 
when prevalent during the winter months of the year. 

In certain epidemics the intestinal disorders are accompanied by such 
a degree of fever, delirium, insomnia, and nervous disturbance that they 
strongly resemble the course of typhoid fever. 

In many cases typhoid fever seems to follow influenza so closely that 
the initial disease becomes merged insensibly in the other, which then 
completes its ordinary course. 

Complications. Pneumonia forms one of the most dangerous com- 
plications of influenza. Its course is slow and insidious, commencing 
during the height of the original disease, or during its period of decline 
and convalescence. It is ushered in by a slight chill, dyspnoea, in- 
creasing cough, and sanguinolent expectoration. Unless intercostal 
neuralgia and pleurisy are present, it is unaccompanied by pain ; but 
there is a greater degree of "dyspnoea than the amount of inflammation 
would justify. The character of the expectoration is less opaque and 
tenacious than that of ordinary pneumonia. There is nearly always 
dulness on percussion, but the auscultatory signs are less characteristic. 
Instead of the fine crepitant rale succeeded by tubular respiration, 
during the first and second stages of ordinary pneumonia, there may be 
entire absence of respiratory sounds, or only a few moist, sub-crepitant 
rales. The tongue is not red and dry, as in ordinary pneumonia, but 
is broad, thick, and covered with a moist and yellowish fur. There is 
often considerable delirium at night. 

In certain cases of influenza there is a marked tendency to hemor- 
rhage from any or all of the cavities of the body. Various eruptions 
have been observed in certain cases; these are erythematous, or they 
resemble the rashes of measles and scarlet fever. Sudamina are some- 
times observed, and herpetic eruptions are not uncommon. Diffuse 



138 PARASITIC AND INFECTIVE DISEASES. 

periostitis has occasionally been observed as a complication of influenza, 
as it sometimes occurs in other infective fevers. Cardiac diseases are 
greatly exaggerated, and are sometimes originated during the occurrence 
of influenza. Acute phthisis sometimes develops in the course of the 
disease. 

Period of decline and convalescence. The duration of influenza is 
exceedingly variable. It sometimes may subside at the end of two or 
three days, or it may continue for two or three weeks, or even longer, 
in complicated cases. Generally, the older the patient the longer the 
duration of the disease, but its course and intensity are often different 
in different epidemics. The decline of the disease is often marked by a 
gradual subsidence of the symptoms ; but sometimes it terminates 
abruptly with some form of critical discharge from the body. Some- 
times a hemorrhage or a cutaneous eruption may occur instead of a 
critical perspiration, diarrhoea, or discharge of urine. A fatal termina- 
tion is generally caused by pneumonia. 

The period of convalescence after influenza is exceedingly prolonged ; 
there is frequently a persistent cough, general prostration, great sensi- 
tiveness to variations of temperature, loss of appetite, and excessive 
fatigue after slight exertion. Relapses are, perhaps, of more frequent 
occurrence than after any other disease. 

Among the secondary diseases that are likely to follow influenza are 
disorders of the nervous system, and catarrhal diseases. Among the 
nervous affections thus induced may be mentioned vertigo, functional 
disorders of vision and of hearing, disorders of taste and of smell, dis- 
turbance of the general sensibility, and. sometimes, intellectual derange- 
ment. Certain cardiac disorders of a nervous character, such as 
palpitation, syncope, cardialgia, and cardiac debility, are often ob- 
served. 

The catarrhal diseases of the respiratory organs often become chronic 
after influenza, and latent tendencies to tuberculosis become quickened 
and established. In fact, the disease seems to prepare the way for inva- 
sion of all the organs of the body by the tubercle bacillus. 

Pathological Anatomy. In severe or fatal cases of influenza the 
blood exhibits a deep color, and its coagulation is imperfect. The other 
pathological appearances are those that are characteristic of mucous 
inflammations and of the complications that have produced a fatal 
termination. 

DIAGNOSIS. During an epidemic of influenza there is a popular 
inclination to invest every catarrhal disorder with the name of the 
current epidemic. In this way it may be frequently confounded with 
acute catarrhal </astro-enteritis. with typhoid fever, or with tuberculosis. 
From all these diseases it may, however, be soon distinguished by its 
course; by the generalization of its symptoms throughout the mucous 
membranes of the entire body ; and by the intensity of the nervous 
prostration that accompanies its evolution. 

Prognosis. Uncomplicated influenza seldom proves fatal : but when 
it attacks patients who are already suffering from previous disorders of 
the thoracic or abdominal organs, or from any cause of general debility, 
its risks are greatly increased. Among young children and old people, 



INFLUENZA — GRIPPE. 139 

complicating pneumonia is the cause of great fatality. During certain 
epidemics, especially those that occur in cold and damp weather, and 
under unfavorable social and hygienic conditions, the mortality has been 
very considerable. Of the three principal varieties of the disease, the 
coryzal or cephalic form, though the most painful, is the least fatal. 
The abdominal form ranks next in the order of danger, while the 
thoracic form is the most dangerous of all. 

Etiology. Influenza is a disease that prevails endemically in the 
eastern portions of Russia and in Central Asia. From these regions, 
under favoring influences of cold damp weather, it extends epidemically, 
and enters Europe, traversing the civilized world from east to west, 
spreading like the cholera in every direction, yet with greater rapidity, 
on account of the volatile character of its contagion. The active agent 
is of bacterial origin, and has been demonstrated as a specific bacillus. 
The various forms of streptococcus, staphylococcus, pneumococcus, and 
other bacteria, have been also found in the mucous discharges from the 
air-passages; and by their invasion of the organism, secondary phe- 
nomena and complicating diseases are produced. 

It is in large cities, where the population is densely crowded, that 
influenza prevails with the greatest virulence. During its prevalence, 
the epidemic tendency induces a predominant occurrence of diseases of 
the respiratory organs, together with neuralgic, rheumatic, and nervous 
affections. There is also a marked tendency to debility and to retarded 
convalescence from the majority of other acute diseases, although their 
course may not be appreciably influenced by the prevalence of influenza. 
Occasionally longer or shorter, the duration of local epidemics varies 
from one to two months. 

Treatment. During the period of invasion, in mild forms of the 
disease, active medication is unnecessary. The patient should remain 
in-doors and in bed ; a hot foot-bath, Dover's powder at night, herb 
teas, lemonade, or whatever drinks may be most agreeable, may be 
allowed in abundance. If the bowels are constipated, a Seidlitz powder 
or a dose of citrate of magnesia will suffice for their evacuation. 
Bronchial catarrh and cough may be relieved by the ordinary mixtures 
that are useful in such cases. Nausea and gastric distress, accompanied 
by severe headache, may often be relieved by an emetic. For this pur- 
pose a hypodermic injection of apomorphia is to be preferred. Minute 
doses of the same drug, in combination with liquor ammonia? acetatis 
and the compound tincture of opium, will be useful. Headache may 
be relieved by antipyrine, phenacetine, and similar preparations ; but 
they must not be continuously administered, because of the nervous 
exhaustion and retarded convalescence which their long-continued use 
occasions. The various preparations of opium, and anodyne combina- 
tions like chlorodyne, are to be preferred in the majority of cases for 
the relief of pain. During convalescence, iron, quinine, strychnine, 
elixir of calisaya-bark, compound tincture of cinchona, and other 
vegetable bitters are needed for a considerable period of time. Good 
diet, and, if possible, a change of air, are needful. The patient must 
guard against exposure to cold and damp, and must avoid fatigue until 
the health is restored. Complications and intercurrent diseases require 
their own specific treatment. 



140 PARASITIC AXD INFECTIVE DISEASES. 



CHAPTEE IX. 

DIPHTHERIA. 

Diphtheria is an acute, infective disease, caused by local contagion, 
producing upon the mucous or cutaneous surfaces of the body an exu- 
dation of false membrane, in which are developed the specific micro- 
organisms of the disease. From these local points of contagion, the 
tissues of the entire body become infected with the products of bac- 
terial life. 

Symptoms op the Disease. Diphtheria manifests itself with vary- 
ing degrees of severity. In certain cases the local lesion is the promi- 
nent feature, while the symptoms of constitutional infection are but 
slightly manifested. In other cases, there is, in addition to active and 
extensive local disease, a development of the symptoms of severe con- 
stitutional infection. In a third class of cases the local symptoms are 
insignificant in their character, while the evidences of universal infec- 
tion are rapidly developed, and are followed by the most serious and 
fatal consequences. These three forms of the disease require separate 
consideration. 

1. The benign form. The local lesions in this variety of diphtheria 
are usually manifested in the throat. It commences with the ordinary 
symptoms of a simple sore-throat, characterized by a chill, considerable 
fever, a feeling of prostration, increase of temperature, and elevation of 
the pulse. These febrile symptoms are sometimes almost, if not wholly, 
absent. Inspection of the throat reveals a reddened condition of the 
soft palate, fauces, and pharynx. In the course of a few hours a thin 
pellicle appears upon some portion of the tonsils or faucio-pharyngeal 
walls. It is the false membrane. At first very thin, white, and 
restricted, it extends and becomes thickened and surrounded by a zone 
of mucous inflammation. It does not extend into the nasal passages, 
but it occasionally descends into the larynx, where, in this mild form 
of the disease, it only occasions difficulty through the partial obstruc- 
tion of respiration. The glands behind the angle of the jaw are some- 
what enlarged, but the evidences of constitutional infection are absent, 
and at the expiration of a week the patient recovers. 

2. The infective form. In this variety of diphtheria the false mem- 
brane may appear in the throat, as in the previous variety, or it may 
be first developed in the nasal passages, or even upon the cutaneous 
surfaces of the body. The false membranes are not limited, as in the 
benign form of the disease, but extend widely, covering the tonsils, the 
walls of the pharynx, the soft palate, invading the nasal passages, the 
larynx, the trachea, and the bronchi. It may also appear upon any of 
the other mucous surfaces, or upon any previous wound or ulceration 
of the skin. The lymphatic glands in the neighborhood of the exu- 
dation become inflamed and enlarged, sometimes even to suppura- 



DIPHTHERIA. 141 

tion. The surrounding areolar tissue also shares in the inflamma- 
tory process. 

The general symptoms at the commencement of the attack correspond 
with those of the benign form, but as general infection progresses, the 
evidences of universal prostration appear. There is no relation between 
the degree of general infection and the amount of febrile disturbance. 
Frequently the most dangerous cases run their course without any con- 
siderable elevation of temperature or disturbance of the pulse. Some- 
times the pulse-rate is reduced to fifty or sixty beats in a minute, and 
the action of the heart is correspondingly enfeebled. If the pulse be 
rapid it is weak and thready. The countenance of the patient assumes 
a mournfully apathetic expression, the eyes become surrounded with 
dark circles, the skin assumes a leaden pallor, and the brilliant color 
of the mucous membranes gives place to a cyanotic hue. There is 
complete loss of appetite, the bowels are usually constipated, but there 
is seldom any other gastro-intestinal disturbance. Albuminuria is not 
uncommon. Hemorrhages from the mucous surfaces frequently occur, 
and there is extravasation of blood at various points beneath the surface 
of the skin and into the tissues of the body. The mind remains clear, 
convulsions sometimes occur, either at the commencement or at the 
close of the disease, in children. Death is the usual termination of 
this form of the disease, though recovery may take place in certain 
cases in which the phenomena of general infection have been compara- 
tively limited. Death usually occurs as the consequence of general 
blood poisoning and exhaustion, or as a consequence of the extension of 
the false membranes into the respiratory passages. Diphtheritic paraly- 
sis usually follows these severe forms of the disease. 

The duration of this form of diphtheria usually exceeds a week. 
Death frequently occurs about the tenth day, though life may some- 
times be prolonged for a month before death or recovery. In certain 
rare cases recovery is effected, though the diphtheritic process may 
persist in the nasal passages for many months, constituting what has 
been described as chronic diphtheria. 

3. Malignant diphtheria. In this form the symptoms of constitu- 
tional infection constitute the prominent features of the disease. In 
certain cases the attack advances with great rapidity, and death may 
remove the patient in less than twenty-four hours, or within three or 
four days at the latest. In these cases the false membranes have not 
time for their complete development, and the patient dies in a state of 
collapse, following a sore-throat that was characterized by very mod- 
erate local changes. In other cases the local phenomena develop with 
great intensity, and tend to generalize themselves most extensively. 
The exudations are of a dirty, pultaceous character, and exhale a gan- 
grenous odor; hemorrhages appear everywhere, the cervical glands 
become greatly enlarged, albuminuria frequently exists, and death 
inevitably follows after the expiration of three or four days. 

In other cases the disease develops insidiously within the nasal pas- 
sages, or in some other concealed locality, so that the initial changes 
may almost escape observation. Fever is usually absent, and there is 
intense prostration with diminution of all the vital functions ; the 



142 PARASITIC AND INFECTIVE DISEASE-. 

patient is inclined to sleep, though perfectly intelligent when awake. 
The countenance becomes pale, the features wear a mournful expression, 
the glands in the neck become greatly enlarged, out of all proportion 
with the limited character of the exudations in the throat or nose. At 
the expiration of about a week, the false membranes disappear, and the 
hope of recovery arises in the minds of the attendants. This, however. 
is I : :ined to disappointment, for the prostration of the patient increases, 
the pulse grows weaker, a fatal restlessness appears, but is often suc- 
ceeded by an apathetic calm which terminates gradually, or sometimes 
abruptly, in death. In other cases the patient seems unmindful of his 
situation, and notwithstanding the evidences of general exhaustion 
is disposed to sit up in bed. to move about, or. if a child, perhaps to 
manifest a languid interest in his playthings until life is suddenly ter- 
minated during some form of muscular effort. 

These insidious forms of the disease are almost invariably terminated 
by death after the duration of a week or ten days. 

Special Symptoms. Fever. There is no conformity between the 
lesions of diphtheria and the febrile movement that may exist. It is 
sometimes wholly absent. It may be very severe at the commence- 
ment of benign cases of the disease, and it usually subsides as malignant 
symptoms become developed. In like manner the temperature does not 
rise in correspondence with the intensity of the disease. The pulse 
may be very rapid and feeble, or it may remain at the normal figure, 
or it may even be depressed below the usual rate. During the last 
hours of the malignant forms of the disease it may fluctuate widely as 
it diminishes in force. The movements of respiration increase their 
rate during the febrile stages of the disease and during the approach of 
death in fatal cases. In other stages of the disease thev mav resume 
their normal course. 

It occasionally happens that during the course of diphtheria certain 
cutaneous eruptions make their appearance: they may be observed in 
all forms of the disease, though they exercise no influence upon its 
course : they often resemble the eruption of scarlatina, measles, ery- 
thema, or urticaria. Occasionally a vesicular form of eruption may be 
presented. These exanthems occur during the first week, and seldom 
>nger than one or two days. In rare instances gangrene of 
the skin has been known to follow a vesicular or pustular eruption. 

Albuminuria occurs not unfrequently during the course of diph- 
theria, as in other infective diseases. It may be discovered in more 
than one- half of the cases. It is of brief duration, and is only occasion- 
ally accompanied by uraemic symptoms. (Edema and dropsy are also 
of very rare occurrence. 

In certain very rare cases sadden death occurs during the course of 
diphtheria, or even during the period of convalescence, as a conse- 
quence of thri nvolving the cavities of the heart, or its nutrient 
vessels. 

DiphtJu During the period of convalescence after 

severe forms of diphtheria, and occasionally after the milder incidents 
of the disease, the phenomena of paralysis are sometimes developed : 
they usually commence from ten to fifteen days after the conclusion of 



DIPHTHERIA. 143 

the original malady, though their commencement sometimes occurs 
earlier, or even much later. 

The symptoms of paralysis are generally manifested by the muscles 
of the palate and fauces; speech becomes nasal and retarded; there is 
snoring during sleep ; deglutition is difficult, and liquids are returned 
through the nose. In severe cases it becomes difficult to swallow solid 
food ; alimentary particles may find their way into the larynx, where 
they excite cough, and sometimes produce suffocation ; the palate 
remains immovable and insensible, reflex and voluntary movements of 
its muscles have ceased ; the tongue, the lips, and the cheeks may 
become invaded by the progressive paralysis ; it may extend to other 
parts of the body and extremities, and may also invade the sensory 
apparatus, though usually limited to the mouth and throat. Commencing 
in the lower limbs, paraplegia is the most common form of diphtheritic 
paralysis when it exceeds its usual limits. The upper extremities may 
also be invaded, and in like manner the neck, the face, the intercostal 
muscles, and even the diaphragm may become paralyzed. Simultaneous 
affection of these muscles is necessarily fatal, but their separate or suc- 
cessive invasion is usually followed by recovery. The muscular fibres 
of the bronchi are occasionally involved, with consequent difficulty of 
respiration and passive congestion of the lungs. The heart does not 
always escape ; its fibres may be invaded to a degree that causes prse- 
cordial distress, cardiac palpitation and intermittence, dyspnoea, tendency 
to syncope, irregularity and weakness of the pulse. These cases are 
frequently fatal. The muscular coats of the intestines and bladder are 
sometimes paralyzed, producing a corresponding disturbance of the 
function of those organs. 

Diphtheritic paralysis usually manifests itself symmetrically upon 
both sides of the body, but sometimes it presents a hemiplegic aspect. 

The various forms of sensibility are liable to share in the paralytic 
tendency; it may be completely abolished in certain localities, but 
usually it is only slightly diminished. The opposite condition of 
hyperesthesia has been discovered in certain very rare instances. 

The organs of special sense are also sometimes affected by the gen- 
eral reduction of power. The visual capacity may be diminished all 
the way to a complete, though usually temporary, loss of sight. The 
pupils are dilated and motionless when both eyes are affected, but they 
are unequal in diameter if one eye only is involved. There may be 
strabismus, consequent upon inequality among the muscles of the eye- 
ball, and the power of accommodation is also lost. These different varie- 
ties of ophthalmoplegia are transient, and terminate in recovery after 
several days, weeks, or months. 

The other special senses are less frequently affected, but the power of 
is sometimes seriously compromised. In certain cases the power 
of articulation is entirely deficient ; in others, it is impossible to articu- 
late labial and lingual sounds ; in others, there is a stuttering or stam- 
mering utterance. When with these difficulties of pronunciation are 
present the phenomena of facial and palatal paralysis, the condition of 
the patient closely resembles that which is produced by labio-glosso- 
laryngeal paralysis. 



Ill PARASITIC AXD INFECTIVE DISEASES. 

In certain instances the tendon reflexes are temporarily abolished. 

The intellectual faculties remain without serious disturbance, though 
the patient may seem to be enfeebled, and his countenance may lack 
intelligence through the more or less extensive paralysis of the muscles 
of expression. 

When the phenomena of paralysis are extensively developed, there 
may be great prostration, marked by constant restlessness, sometimes 
accompanied by convulsions and coma. Difficulty of deglutition may 
produce such a disgust for food that the patient may fall into a state of 
marasmus and inanition marked by vomiting, diarrhoea, and profound 
cachexia. Fortunately, however, the majority of paralytic cases result 
in recovery ; the degree of mortality is only about twelve per cent. 
The lower limbs are the first to resume their function ; recovery usually 
progresses in the order of the attack, so that the muscles which were 
first disabled are the first to recover their function. 

The duration of diphtheritic paralysis is exceedingly variable ; when 
confined to the muscles of the throat it may not continue longer than a 
week, though its duration is usually much more considerable. When 
the paralysis becomes general, it frequently persists for a number of 
months ; it rarely continues longer than six or eight months, though 
cases of permanent weakness, involving a limited group of muscles. 
have been occasionally observed. 

Diphtheritic paralysis may follow any of the forms of diphtheria. 
The frequency of this sequence is exceedingly variable in the experi- 
ence of different observers. According to Sanne, it was eleven per 
cent, in a total of thirteen hundred and eighty-two cases that passed 
under his observation. 

Pathological Ax atomy. The false membranes of diphtheria con- 
sist of an exudation that is formed upon a highly inflamed mucous sur- 
face, or upon cutaneous surfaces that have been subjected to previous 
injury. The exudation appears at first in the form of minute, thin, 
opalescent or white patches that increase in thickness and become of a 
dirty or yellowish color, presenting the appearance of a necrotic spot in 
the mucous membrane. As a consequence of local infection the epi- 
thelium of the invaded portion is compressed and degenerated by the 
infiltrating exudation, which consists of coagulable lymph that forms a 
delicate network of fibrinous filaments among the epithelial structures 
and connective tissue of the mucous membrane. Involved in this net- 
work, appear numerous leucocytes, blood corpuscles, and parasitic bac- 
teria. Among these mav be discovered, about the second or third day, 
the pathogenic bacilli which are the cause of the disease. The tissues 
beneath the false membrane contain round cells, fibrinous filaments, and 
other products of inflammation. The blood and lymph vessels are 
dilated and distended. The mucous glands are in a similar state of 
distention. The glands of the tonsils exhibit great congestion, with an 
exudation into their ducts which is continuous with the external false 
membrane. In mild forms of the disease, the mucous membrane is 
but slightly altered beneath the false membrane : but in severer forms 
of the disease the exudation penetrates beneath the mucous surface. 
Within the air-passages, which are lined with cylindrical epithelium. 



DIPHTHERIA. 145 

the products of exudation are less adherent and may be easily detached. 
The lymphatic glands in the neighborhood of the seat of exudation are 
infiltrated by a serous liquid containing bacteria. The elements of the 
glands are increased by cellular proliferation and infiltration. Many 
of the cells have undergone degeneration or even destruction through 
the compression to which they have been subjected. As a consequence, 
small abscesses are frequently found in the lymphatic glands. 

The kidneys are almost invariably affected, and an acute, diffuse 
nephritis is universal. This, however, does not invade the organs sym- 
metrically or totally, hence the rarity of uraemia and dropsy in connec- 
tion with diphtheria. 

The blood exhibits the characteristic appearance caused by the disso- 
lution of its elements. It is a dark fluid, with absence of fibrin, or it 
may present the appearance and consistency of gooseberry -jelly, pro- 
ducing loose and soluble clots in the heart and large vessels. The red 
blood-corpuscles are largely reduced in number, and their haemoglobin 
is diminished in quantity. 

The organs of respiration may present any of the different acute 
diseases to which they are liable. The heart and the pericardium are 
sometimes affected, as in other infective diseases, by the inflammatory 
and degenerative alterations. To the same class of changes must be 
referred the atrophy and fatty degeneration of the muscles, which espe- 
cially occur in those muscles that lie nearest to the diphtheritic exuda- 
tions. 

In the spinal cord, the gray matter and its neuroglia exhibit evi- 
dences of a slight inflammation, which also involves the anterior roots 
of the spinal nerves. This inflammatory affection reaches the motor 
fibres of the peripheral nerves, and may be traced as far as their intra- 
muscular terminations, thus explaining the paralytic condition of the 
muscles with which they are connected. 

Etiology. Diphtheria is a disease that prevails epidemically in 
newly settled countries where it has not previously been known, but in 
old and densely populated communities it tends to become endemic. 
It is now persistent in all the large cities of the northern hemisphere 
that lie within the temperate zone. Its prevalence and its virulence 
are aggravated in proportion to the severity of the climate and its 
nearness to the northern limits of population. Cold, damp weather, 
such as prevails during the spring and autumn of the year, favors the 
spread of the disease. Warm weather, that helps free ventilation of 
habitations, causes its decline and disappearance. 

Diphtheria is an emphatically contagious disease. It may be trans- 
mitted directly from person to person by particles of matter derived 
from the focus of inflammation. In this way, physicians, nurses, and 
companions of the sick are continually infected. In the act of cough- 
ing, contagious particles are driven into the face of the attendant, and 
finding lodgment upon the respiratory mucous membranes, become 
centres of infection. Physicians have lost their lives through an incau- 
tious zeal that has impelled them to attempt the dislodgment. by suc- 
tion, of mucus from a tube that had become clogged after the operation 

10 



146 PARASITIC AND INFECTIVE DISEASES. 

of tracheotomy. Children have been infected bv nursing the breast of 
a mother who had just previously given suck to a diphtheritic infant. 

That diphtheria may be transmitted by inoculation is a fact of daily 
demonstration in the laboratories of pathology, where the transmission 
of the disease to animals, for purposes of experimentation, is a matter 
of frequent occurrence. In like manner, human subjects have been 
accidentally inoculated in the course of operations for the relief of diph- 
theritic patients. In the majority of cases such inoculations have 
proved harmless, but in certain instances they have resulted in the 
development of the disease. The probability of such inoculation is 
greatly increased if it be effected by contact with fragments of the false 
membranes of diphtheria or with the liquids which they contain, for 
the reason that it is in these that the contagious virus exists. 

The contagion of diphtheria maybe transmitted through the medium 
of the atmosphere that surrounds the patient. Minute particles of 
false membrane find their way into the air during the act of coughing 
or expiration. Dry fragments of false membrane become pulverized 
and rise in the form of dust in the air of an ill-ventilated apartment. 
In this way a susceptible person may become infected by simple entrance 
into the house where diphtheria is prevailing. Particles of false mem- 
brane that have become temporarily attached to clothing and fur, the 
hair of animals, or other movable articles, may contaminate the atmos- 
phere at a distance from their original source. Falling upon the 
mucous membranes of the respiratory passages, or upon denuded sur- 
faces of the skin, they become centres of contagion. 

It thus appears that the propagation of diphtheria depends in every 
instance upon the transmission of a contagion that is derived from the 
false membranes that are produced in the course of the disease. The 
active agent of this contagion is a minute bacillus, discovered by Loffler. 
Numerous observers had demonstrated the existence of bacteria which 
swarm in great variety in the substance of the false membrane, but he 
first demonstrated the fact that the active and specific agent is a bacillus, 
of which the length is about the same as that of the tubercle bacillus, 
but its diameter is somewhat greater. It is either rectilinear, or slightly 
curved at one of its extremities. The larger specimens appear to be 
composed of several segments, and they are slightly thickened at their 
extremities. Besides these pathogenic bacilli, the pyogenic bacteria, 
staphylococcus and streptococcus, are also present, but they have nothing 
to do with the direct causation of the disease. 

The diphtheritic bacillus proliferates extensively in the substance of 
the false membranes, but does not penetrate into the Mood or into the 
organs of the body. It is confined to the primitive fccus of the dis- 
ease, where it secretes a chemical poison that enters the circulation and 
is transmitted to every part of the body. This poison has been isolated 
and may be preserved, either in the liquid state or as a desiccated mass 
that retains its active properties for a long period of time. Injected 
into the bodies of animals, it produces virulent effects identical with 
those that are produced by inoculation with the false membranes of 
diphtheria. 

From these considerations it follows: 1. That diphtheria is a local 



DIPHTHERIA. 147 

disease produced by contact with matter that is charged with a specific 
bacillus. 2. That the growth and multiplication of this agent results 
in the development of a specific inflammation at the point of contact, 
with production of a false membrane that is infested with pathogenic 
microorganisms. These do not spread beyond the seat of inflammation, 
but they generate a diffusible poison that is conveyed to every part of 
the body, and produces the successive phenomena that characterize the 
general course of the disease. 

The relation between climate and weather and the propagation of 
diphtheria has already been mentioned. It is probable that the exist- 
ence of catarrhal inflammations of the throat operates powerfully as a 
predisposing condition for the reception of diphtheritic contagion. For 
this reason the disease prevails more frequently and with greater viru- 
lence among children, who are particularly liable to inflammatory con- 
ditions of the respiratory passages. Social misery, with all its accom- 
panying defects of hygiene, by effecting a reduction of physical vigor, 
may also predispose to the occurrence of diphtheria ; but only in this 
indirect manner can such conditions operate. Adult life, good hygiene, 
dry climate, wholesome habitation, and the absence of predisposition to 
disease, constitute the conditions most favorable to avoidance of the 
invasion of diphtheria. 

Previous experience of the disease affords no protection against its 
recurrence, though it is believed that the first attack is more dangerous 
than subsequent invasions. 

Secondary Diphtheria. Diphtheria may occur as a complication of 
other infective diseases, either in their course, or as their sequel. It is 
most frequently observed in connection with measles, scarlet fever, 
tuberculosis, and whooping-cough. After these, though at a consider- 
able distance, may be numbered typhoid fever, bronchitis, pneumonia, 
pleurisy, and smallpox. Scarlet fever is more frequently than measles 
associated with diphtheria. The apparent preponderance of measles 
is owing to the greater prevalence of that disease, affecting the entire 
population, while scarlet fever attacks only a moderate number. It is 
through the inflammatory condition of the respiratory passages by which 
these diseases are characterized that predisposition to diphtheria is pro- 
duced. Previous inflammation prepares the way for the reception of 
diphtheritic contagion. 

Diagnosis. The occurrence of sore-throat, with an abundant exu- 
dation of false membranes upon the tonsils, fauces, or pharyngeal mucous 
membrane, accompanied by swelling of the glands behind the angles of 
the jaw, cannot be mistaken for any other disease than diphtheria; but 
there are cases in which the absence of local symptoms in the throat, 
and the lack of definition in the general symptoms render diagnosis dif- 
ficult. It is well to remember the advice of Trousseau, who recom- 
mended a careful examination and search for the manifestations of 
diphtheria in every case where an infant exhibits ill-defined symptoms 
of disease that cannot be readily referred to a specific cause. In such 
cases inspection of the fauces will frequently throw unexpected light 
upon the nature of a malady about which a nursling is unable to utter 
any complaint. Mild forms of the disease can be scarcely distinguished 



IrtS PARASITIC AXD INFECTIVE DISEASES. 

from simple cases of catarrhal tonsillitis. Malignant cases that termi- 
nate fatally in the course of a few hours may sometimes occasion doubt 
as to the diagnosis ; but their occurrence in the course of an epidemic, 
and the existence of catarrhal symptoms involving the respiratory 
passages, should render the diagnosis quite certain. In local house 
epidemics it is not uncommon to observe varying grades of intensity 
in the symptoms that are manifested by the different members of an 
infected family. All such cases are, however, infective, even in the 
mildest form. 

It is in the insidious forms of the disease that the greatest difficulty 
attends the diagnosis at the commencement of their course. The local 
manifestations of the disease may be concealed in the posterior nasal 
passages, and only the general symptoms of constitutional infection 
attract attention. In such cases the course of the disease will suffice to 
clear up the diagnosis. Initial somnolence, slight fever, general pros- 
tration, utter loss of appetite, enlargement of the cervical glands, a 
slight discharge from the nostrils, a leaden pallor of the countenance, 
an expression of listless sadness, hemorrhagic discharges from the 
mucous surfaces of the body, with or without petechial eruptions, heart 
failure, collapse, and death, form an assemblage of symptoms that can 
scarcely be ascribed to any other known disease. Even though no 
visible false membrane may appear before death, a carefully conducted 
autopsy will, however, invariably reveal a local origin for the disease. 

Prognosis. From the preceding considerations it follows that the 
prognosis of diphtheria is exceedingly uncertain. The malignant forms 
are always dangerous. The greater the rapidity with which the dis- 
ease develops, and the greater the extent of the false membranes, the 
greater the dangers that accompany the course of the disease ; but many 
a mild form of the malady becomes insidiously transformed into a most 
malignant case before its fatal termination. The occurrence of false 
membranes in the nose, or upon the conjunctiva, in the Eustachian 
tube, or about the organs of generation, is a most portentous circum- 
stance. Invasion of the larynx and bronchi is attended with a high 
rate of mortality ; though dyspnoea may be relieved by the operation of 
tracheotomy, the patient still remains liable to death from constitutional 
infection. 

Secondary diphtheria is always attended with extreme danger. 
Relapsing diphtheria is far less dangerous. 

The age of the patient exerts a great influence upon the rate of 
mortality. The greatest fatality is experienced during the first three 
years of life. Old people and those who have been exhausted by pre- 
vious disease, or unfavorable conditions of existence, also exhibit a 
high rate of mortality. Sex appears to exert no particular influence 
upon the course and termination of the disease. Congenital tendencies 
to tuberculosis, such as are indicated by the so-called lymphatic or 
scrofulous diathesis, add considerably to the dangers of diphtheria : 
such patients lack the degree of stability that is necessary for successful 
resistence to the diseae 

Treatment. Mild and uncomplicated forms of diphtheria recover 
spontaneously without treatment, though they may be occasionally fol- 



DIPHTHERIA. 149 

lowed by the symptoms of paralysis. Severe forms of diphtheria 
demand the most energetic treatment that can be furnished from the 
resources of medicine and surgery. 

The management of diphtheria demands, in the first place, attention 
to the restriction of the disease, so that it shall not spread to others 
from the original patient. For this purpose all persons, excepting those 
who must care for the sick, should be excluded from the house. Phy- 
sicians and attendants must observe every precaution against contagion. 
The utmost cleanliness must be secured by frequent washing of the 
hands with antiseptic lotions, and by gargling of the mouth and throat 
with solutions of boracic acid, salicylic acid, or permanganate of potas- 
sium. All articles of clothing that have been used about the patient 
should be placed for twelve hours in a five per cent, solution of carbolic 
acid before they are boiled and washed. 

The treatment of diphtheria consists in the employment of remedies 
that are directed, in the first place, against the local disease, and against 
general intoxication of the system, in the second place. The local 
applications in the throat should have for their object the disinfection 
and destruction of the false membranes. For this purpose the fauces 
and pharynx may be swabbed with a solution containing one part of the 
corrosive chloride of mercury, and five parts of tartaric acid in 1000 
parts of distilled water. With this solution the membranes may be 
wiped off from the mucous surface ; at the expiration of an hour the 
operation may be repeated. It is seldom necessary after such thorough 
application of the remedy to reapply it more than twice a day. Forci- 
ble removal of the false membranes, and cauterization of the throat 
should be avoided, because all such local injuries favor the absorption 
of the diphtheritic virus. Additional disinfection of the mouth and 
throat may be secured by frequent irrigation with solutions containing 
either 2 per cent, of carbolic acid, 4 per cent, of boracic acid, 2 per 
cent, of salicylic acid, or 1 per cent, of thymol. Adults and children 
of considerable age can easily be treated by this method, but young 
children who cannot understand the object of such disagreeable opera- 
tions must be dealt with in a very summary w T ay. The little patient 
should be wrapped in a sheet so that he cannot use his hands or his feet, 
and should then be placed upon the lap of his nurse, by whom he is firmly 
held. A second person standing behind the nurse should place a hand 
upon either temple of the child, and at the same time press upon the 
cheeks or compress the nostrils in such a way that the patient must open 
his mouth. A suitable gag must then be placed between the teeth, and 
in this immovable position the mouth and throat may be easily and 
thoroughly irrigated by means of an ordinary irrigation-tube. Nasal 
diphtheria may be reached in the same way by introduction of the tube 
into the nostrils. 

For the purpose of facilitating the solution of the false membranes, 
they may be swabbed every four hours with lactic acid ; or with chino- 
line five parts, alcohol and distilled water each fifty parts ; or every four 
hours with a solution containing one part of papayotine in twenty parts 
of distilled water, with hydrochloric acid sufficient to give an acid 
reaction. 



150 PARASITIC AXD INFECTIVE DISEASES. 

Various powders have been recommended for application by insuffla- 
tion into the throat, e. g., quinine, sulphur, borax, benzoate of sodium, 
iodoform, salicylic acid, chloride of sodium, and finally pulverized 
sugar. Patients of age and intelligence sufficient to enable them to 
employ gargles, may be instructed to use for this purpose lime-water, 
or a two per cent, solution of chlorate of potassium, or alcohol and 
water of a strength that can be tolerated, permanganate of potassium 
in solution, etc. An excellent gargle may be prepared with chinoline 
one part, alcohol fifty parts, and distilled water five hundred parts. 

If it be thought desirable to make use of medicated inhalations, thev 
may be administered with an ordinary spray-producing apparatus. 
Chlorate of potassium in two per cent, solution ; carbolic acid of the 
same strength ; corrosive chloride of mercury in a very dilute aqueous 
solution ; peroxide of hydrogen : lactic acid ; oil of eucalyptus ; oil of 
turpentine ; benzoate of sodium, etc., have all been employed in this 
manner. 

.As a part of the local treatment may be considered the adminis- 
tration of ice, and the use of chlorate of potassium with tincture of 
sesquichloride of iron, which has been so extensively employed. 

The general treatment of diphtheria demands attention to the nour- 
ishment of the patient. A diet of milk, raw eggs, rich broth, pepto- 
noids, and minced meat, should be given in sufficient quantity. If the 
patient will not, or cannot, take food by the mouth, it should be admin- 
istered by injection into the rectum. Among the most important 
therapeutic agents in the treatment of diphtheria, is alcohol, which 
antagonizes the poisonous excretions of the diphtheritic bacillus very 
much as it operates to prevent the influence of snake poisons and other 
virulent substances. It may be administered in any form that is agree- 
able to the patient, and to any extent short of actual intoxication. 

Febrile symptoms, if present, may be antagonized by the administra- 
tion of antipyrine in doses proportioned to the age of the patient. In 
cases marked by a high temperature, the employment of baths and 
hydropathic measures has been found highly beneficial. 

Oil of turpentine in an emulsion, of which a teaspoonful containing 
five drops may be given every three hours, has been considered a remedy 
of great value. It may be given also in a mixture containing four parts 
of the oil with one part of the spirits of ether. To children under five 
years of age, a teaspoonful of this mixture may be given every day ; 
to older children a double dose, and to adults a tablespoonful. 

In cases marked by great prostration, powerful heart stimulants, such 
as camphor, ether, and musk, must be employed. 

Invasion of the larynx and trachea by the diphtheritic membrane 
requires a renewal of vigor in the employment of medicated inhala- 
tions. For this purpose are recommended lime-water and distilled 
water in equal parts ; or one part of the corrosive chloride of mercury 
in 4000 parts of distilled water ; or five to ten parts of the oil of 
eucalyptus with twenty-five parts of alcohol in 180 parts of distilled 
water ; or a two per cent, solution of carbolic acid. With the develop- 
ment of the symptoms of laryngeal obstruction it is advisable to have 
recourse to the use of emetics. Syrups of ipecac and squills may be 



TETANUS. 151 

given every ten minutes until vomiting is produced. If this fails to 
give relief, intubation of the larynx may be performed ; but if this 
measure prove insufficient, the operation of tracheotomy must be per- 
formed without delay. The period of convalescence requires a free use 
of iron, quinine, and alcoholic stimulants. Paralysis and other com- 
plications must be treated in accordance with the general principles 
that control their medication. 



CHAPTEE X. 

TETANUS. 

Etiology. Tetanus is frequently excited by the infection of a wound 
with impurities containing a specific bacillus, the tetanus bacillus. 
Sometimes the disease occurs though it be impossible to detect any 
wound or external injury through which an infective process could be 
excited. The virulent microphytes exist in the soil, especially in cer- 
tain localities where the disease frequently occurs among animals and 
men whose feet have been wounded and impregnated with infected 
mire from the roads or fields. The bacilli proliferate in the wound to 
which they have obtained access, but do not pass thence into the 
tissues throughout the body. They secrete upon the spot a poison 
which is slowly absorbed and infects the body at large, producing the 
symptoms of the disease principally through its action upon the 
nervous centres. The infective substance belongs to the class of tox- 
albumins ; it is a soluble, diifusible, chemical compound which acts by 
virtue of its chemical properties upon the tissues of the body. 

Tetanus occurs more frequently in certain localities than in others. 
It is especially common in warm climates during the hot season of the 
year. Considerable variations of temperature favor the occurrence of 
the disease, as when cold nights succeed hot days. A neglect of hygie- 
nic precautions, with residence in close, unventilated, and filthy houses 
are also favorable to its manifestation. Under such circumstances 
newborn children frequently fall victims to tetanus (tetanus neonato- 
rum), the infective process being usually accomplished through lack of 
cleanliness in the care of the umbilical cord. The disease is often 
encountered as a consequence of bullet wounds and other injuries 
received in battle. It is especially frequent among the wounded 
soldiers of the defeated army who are compelled to march or are trans- 
ported under depressing circumstances during bad weather, and are 
exposed to privation and misery beyond description. 

The attempt to show that certain races are more susceptible than 
others to tetanus has failed to indicate anything more than the fact 
that habits of cleanliness and wholesome living are more carefully 
practised in certain regions of the world than in others. The more 
frequent incidence of the disease among males in middle life is due to 



152 PARASITIC AND INFECTIVE DISEASES. 

the fact that such people are most exposed to injuries and to the causes 
of infection. 

The nature of the injury exerts considerable influence upon the 
occurrence of the disease. It is more often observed after contused 
and ragged wounds into which foreign bodies have been forced in the 
act of traumatism. Wounds of the extremities are more liable to in- 
fection than those of the trunk, probably on account of their greater 
exposure to uncleanliness. Minute punctured wounds also seem to be 
more dangerous than those which are wide and gaping. Sometimes 
tetanus is developed after simple concussions of the brain and of the 
spinal column. 

Tetanus sometimes occurs as a consequence of infection through the 
uterine passages after childbirth or abortion. Infection may also 
occur through ulcers in the rectum, to which the infective agent has 
found access through the medium of a clyster. 

It was formerly supposed that rheumatism might act as an exciting 
cause of tetanus, but it is now believed that rheumatism and exposure 
to cold and wet merely act as predisposing causes which facilitate the 
action of the specific contagion. It seems to be, however, admitted 
that sometimes it is impossible to discover the mode of infection ; to 
designate such cases, the term idiopathic tetanus is employed. 

Symptoms. The period of incubation is of uncertain duration. It 
occasionally occupies only a few hours, but it is frequently prolonged 
through an entire week. 

The invasion of the disease is usually gradual. Sometimes the 
infected wound changes color and becomes painful. The nerves that 
extend from the wound toward the central nervous organs become the 
seat of pain. The patient is restless and irritable. Pain and stiffness 
are presently experienced in the neck, fauces, and jaws, and finally 
the muscles are invaded by the characteristic tetanic spasm. 

It is in the muscles of mastication and deglutition that the first 
symptoms of spasm are manifested. The muscles of the neck are then 
invaded, and finally the muscles of the back, body, and extremities 
participate in the disease. The occurrence of spasm in the muscles of 
mastication is designated by the term trismus. In adult cases the 
muscles of the extremities sometimes escape, but in children all the 
muscles of the body and extremities participate in the convulsive 
paroxysm. When the disease is fully developed, the eyebrows are ele- 
vated ; the forehead is wrinkled ; the nostrils dilate ; the corners of the 
mouth are drawn upward and outward, revealing the teeth, which, 
however, cannot be separated by reason of tonic spasm of the masseter 
muscles ; the head is drawn backward ; the spinal column is stiffened 
and arched ; during the paroxysms of tonic convulsion the weight of the 
body is frequently supported upon the back of the head and sacrum, con- 
stituting the condition that is known as opisthotonus. The muscles of 
respiration share in the spasm, so that breathing becomes difficult, and 
the blood is very imperfectly aerated. Death not unfrequently results 
from spasm of the glottis and suffocation. The abdominal muscles are 
contracted and hard ; partial priapism often exists, and all the muscles 
of the extremities are thrown into a state of rigid contraction. 



TETANUS. 153 

In some cases a condition of tonic spasm continues with scarcely 
any remission, only varied by recurrent exacerbations of convulsion, 
while other patients experience intermissions of considerable duration 
between the tetanic paroxysms. In such cases clonic convulsions are 
sometimes witnessed, and it is evident that there is great increase of 
reflex excitability ; the slightest touch, breath of air, sudden increase 
of light, or an audible sound may suffice to excite a convulsive 
paroxysm. 

Consciousness is usually retained during the greater part of the 
disease, but sometimes the mind wanders toward the close of life. The 
patient is alive to his danger, complains of soreness and pain in his 
muscles, and experiences the most doleful forebodings of evil. 

In many cases the temperature remains without change. It is 
sometimes subnormal, but occasionally it is greatly elevated shortly 
before death, a fact that indicates the extension of the disease to the 
regulative centres of the brain. 

The pulse is usually accelerated and is sometimes quite irregular. 
The skin is generally covered with perspiration as a consequence of 
paralysis of the regulative centres in the cord and brain. Cutaneous 
sensibility remains without notable change. The reflexes are usually 
increased, but are sometimes diminished. 

The bowels are constipated, and urine is evacuated with difficulty. 
It is scanty, high colored, and often contains urates. Sometimes also 
albumin and sugar are present. 

The duration of the disease is exceedingly variable. It is customary 
in this connection to cite the case of a negro who died within fifteen 
minutes after infection. Sometimes the disease is protracted for many 
weeks, and months may elapse before all traces of its existence dis- 
appear. Sometimes paralytic conditions are manifested after the 
subsidence of the convulsive phenomena. 

Death usually results either from suffocation, exhaustion, or hyper- 
pyrexia. Bronchitis, pneumonia, and acute nephritis have been 
observed as complications of tetanus. 

A special form of tetanus, designated cerebral tetanus or hydrophobic 
tetanus, has been observed after injuries of the head, especially in the 
neighborhood of the eyebrow. Trismus and facial paralysis occur 
upon the side of the injury. Sometimes the paralyzed muscles remain 
in a condition of contracture, resembling spasm rather than paralysis. 
The act of swallowing is difficult. Sometimes general tonic convul- 
sions are developed, and the disease frequently terminates in death. 
In certain cases of injury involving the extremities, a local tetanus is 
developed in the neighborhood of the wound, but this localized form of 
the disease- may subsequently become merged in the general muscular 
spasm of universal tetanus. 

Pathological Anatomy. The pathological changes that persist 
after death are largely the result of excessive muscular contraction and 
capillary extravasation of blood into the muscular substance. The 
nerves in the vicinity of an infected wound frequently exhibit a moder- 
ate degree of redness with swelling. In newborn children the umbil- 
ical artery and vein exhibit evidences of inflammation. Trifling 



154 PARASITIC AND INFECTIVE DISEASES. 

meningeal hemorrhages are frequently observed. These have nothing 
to do with the causation of the disease, but are the consequences of 
suffocation and of stagnation of the blood. 

Diagnosis. Tetanus may be differentiated from spinal meningitis 
by the absence of trismus in the latter disease. In cases of simple 
spasm of the masticatory muscles the cervical muscles remain un- 
affected. Acute muscular rheumatism of the back is unaccompained 
by trismus. 

Prognosis. The disease is always attended with great danger. 
Probably more than half the cases prove fatal. The longer the dura- 
tion of the disease, the greater the probability of recovery. A long 
period of incubation is also more favorable than a rapid development 
of spasm. 

Treatment. The greatest care should be taken to insure perfect 
cleanliness in all wounds. Exposure to cold and other depressing 
causes should be also avoided. Ragged and punctured wounds should 
be converted as far as possible into clean incisions. 

After the development of the disease the patient should be nourished 
with liquid diet, since it is impossible to masticate solid food. The 
bowels should be evacuated with calomel and jalap, and the patient 
should be kept under the influence of chloral hydrate, which may be 
given to the amount of from half a drachm to a drachm and a half each 
day. All kinds of narcotic and neurotic remedies have been employed, 
but with indifferent success, since those which are really powerful to 
influence the nervous system are dangerous Avhen given in sufficient 
doses. Alcohol, chloral hydrate, and the bromides are most useful 
and least attended with danger. Recently the discovery of an anti- 
toxine or counter-poison in the blood of tetanized animals, has been 
followed by its isolation and employment as an antidote to the infective 
toxalbumin that is secreted by the tetanus bacillus. The injection of 
this counter-poison into the circulation of a tetanized animal serves to 
neutralize the effects of the contagion, and is followed by recovery. 
A similarly successful issue has been obtained in the treatment of 
tetanus in the human subject, so that there is reason to hope that the 
means of successfully combating the disease may be obtained through 
the artificial production of a chemical compound identical with the 
antitoxine that is actually produced during the reaction of the infected 
tissues. 



CHAPTEE XL 

TUBERCULOSIS. 

Tuberculosis is an infective disease produced by an invasion of the 
organism by the tubercle bacillus, first discovered by Koch in the year 
1882. The wide diffusion of this bacillus, and the great differences 
among the local disorders that are produced by its vegetation in the 




TUBERCULOSIS. 155 

organs and tissues of the body, give to the tubercular process a 
remarkable degree of variety in the mode and form of its evolution. 

The length of the tubercle bacillus is usually about one-quarter or 
one-half the diameter of a red blood-corpuscle, though its dimensions 
may vary considerably beyond these limits. The little parasite may be 
easily rendered visible by the method of Ehrlich, which depends upon 
the fact that when the bacillus has been stained by immersion in an 
aniline dye, it resists the decolorizing 
action of nitric acid. (Fig. 77.) The FlC} - H. 

bacilli are either straight or curved. V |jj 



Their substance is homogeneous, or it - v - , 

may be formed of little, rounded masses v ~- 

that are discontinuous. Sometimes <^ / 7 

little, colorless points are visible within / / ^ '_ 

the protoplasm of the bacillus, and '', 

these have been supposed to indicate ... . v ' f /7 V 

the presence of spores. tj _ ^ /'<* 

The microscopical demonstration of f '>\~ %lJ/} ~. r < 

tubercle bacilli can be most conveniently 
performed as follows : A minute portion 
of the semi-solid or cheesy contents of 
a tubercular deposit, such as may be 

found in the sputa, should be placed Bacilli of tubercle from sput , 
between two cover-glasses and subjected x 500. (Bristowe.) 

to pressure by the thumb and finger. In 

this way the mass is easily spread out between the two glasses, which 
should then be separated from one another, leaving a thin layer upon 
each glass. These should be then partially dried by passing them 
several times through the flame of a spirit lamp, with the sputum side 
upward. They are then ready for the staining fluid, which consists of 
a concentrated alcoholic solution of fuchsine. A little aniline oil should 
be poured into a test-tube, which is then to be filled nearly full of dis- 
tilled water. The two liquids must be thoroughly shaken together, 
forming a mixture in which a little of the aniline oil is dissolved in the 
water. This mixture should be filtered, and a portion of the filtrate be 
placed in a large watch-crystal. From five to ten drops of the solution 
of fuchsine should be then added to the contents of the watch-glass, and 
upon the mixture the cover-glasses are to be floated with the sputal 
surface downward. The watch-glass should be placed for twenty-four 
hours under a cover, to protect it from dust ; or, if an immediate 
examination be desirable, the liquid may be heated over a flame until it 
boils. After lying for ten minutes in this heated fluid, the cover-glasses 
are ready for bleaching. They should be placed for a short time in a 
small quantity of absolute alcohol to which a drop of pure nitric acid 
has been added. As soon as the coloring matter appears to have con- 
siderably faded from the sputum-covered surface of the glass, the slip 
should be removed and washed with distilled water. It may be then 
mounted with Canada balsam, and placed under the microscope, where 
it will be perceived that the coloring matter is still retained by the 
bacilli, while the remaining portions of the sputum are colorless. A very 



FAfcASaTIC: ASCI* INFECTIVE Drt^ iSSS 

btfaaaniy eieet may be paredweed by staining a&e- background of abe 
snraaee wiiab laaallaebiae green, wbieh eonarasas admirably witb the 
ikfeiM' Binge of afoe taeiffli. 

Aneuber exeeHHena aae«bod eonsists in abe snbstiantjon of a earbelie 
stofenawn o& fcyi«» Gene para of eoneenaraaed aleebolie solution of 
tWbsine* nine paint* of a. five p>er eena. solution dT earboJie aeid) for tbe 
sfraimkig^bid previously teriki By warming this iuid. tbe porepa- 
r*3 km earn be etfaaplleaed in a few aninuaes. Tne background mar be 
stained w icb am aoneous s0>Diftldk«n of moth \ leneJhrae. Tie whale y I 
earn be greaaly abbreviated % simply mefetoenin^ with tbe sAaumn^-Au«l 
-Bue- Jajer oiT s^raitttauQa wpm abe eover-gllass* aben warming it quiekhr ever 
a iafine* and wasbing wiab distillled water. 

Many animate- ean ttV i % imim&aSim with aubereular matter. 

Tbfe s s aIv true ofi abe graminiverous animals. Tbe earnivora,, 
pjrioBKMjpa% abe dog ammi tbe can. are net eas% thus infeeaed. If liquids 
iaa wfc&i abe bacilli bave been enlaivaajed be snbjeeted tv> filtration 
ttBtor^tg^i ungjDaaed pioreeJain,. abe miiierft&i^^ the 

ffltoery, am^ abe fUtnratte loses ias infective properties,, tat stall contains 
albuminoid snbsoanees abat in a ea nwntrated term possess toxic prop- 
eraies*. From abe filtoered Bjpaid may be separated an albuminoid sub- 
stance abat„ wben injected into tne body of an animal, produces an 
elSevatsw)© of abe tenapiMfaBiaire tbat pier^te; iW one ear two days. Besides 
ttfea» to^tamin,, tifoere is a substance abat resembles the pftomalnes* 
and is p© canons to ffirogs. From abe taettem themselTes ma y be eb- 
taioie^ asu ak«Mti : vMeh exdites tesaniierm eizmTaBsHHis in the 

guinea-pig,, and parodaiiees deattn aifter a. tew nemrs. Aneaner extraetiTe 
exni^ias p>ye^nie ^aBiiaies. CNtner aoaw snabsaanees hare also been 
iBuBaaed feca entoaes ef tne aaaWawlle baeilks wMeh prednee danmens 
and rasa! resnlhts wnen anjeeaed inao. aibe bediies ef anamals. These 
esptfiriffliienas of a&ie llabisraasMry serve tto> explaiin many e£ the symptSMns 
anat awoimpaflBiT ajbe infteaive paroeess and abe evelaiajien of taberenksas 
nnBideir oanfcainr es^ndiiaiens. 

Tne viiaalay ef abe itnberdle baeiOfllns as very great. Alternate ex- 
posoare- w> desiietfaa wn and to n&ebsanre aer many mentbs is witnont e&Vet 
nptisn ias offganiaaaiKDm. It may be immersed lor monabs in water; it 
HiiaTWesp0sedira>p«it^ 

- ^wever^ deswroyed bv espiosnre to tne beat of ebullition aor fbnr 
or nve miinnaess and ia pjeryhes rapidity under the inlnenee of s?an%ba. 

Tne izaJte^iwja <?!' anberedDesas may be taansmittted from one bi 
beang to anoaner^ tnoan^i tbk oeenrs rareJy. and only minder the 
tavovabDe esiuiiaiksiins. Tne parasiae is eontamed only in tne 
oaber BagmM exetreaa^ so abat abe danger of iadfoetiion eonsi^as 
imii ulkje- iiisjBiiaJaTiijOiDi *d£ t^hrieiifi pairtiijeile^ ^smiia&iBiiiinL^: featduML. Tne tnberedk»» 
of eaatDe may be wiumafinieatted to bnman beings tbrongh abe medmm 
'>:£ abe dii^estiive QB<gws>. Tne lesb of tnberenmr eattHe is inieetive to 
e«raaiin aniinaaJk. wbole ottbers may devonr it witbont barm. It is by 
many beffiieved abat abe inawti ve agent is located in abe Ivmph gjbnds* 
rattber aban in abe maseallar smbetianee. It may be destroyed by 
aboron^b ey ijkiin^. but abe aemjBeraamre to wbieb roast beef is vsnaDy 
srnap- - sarifiisMtfoltnis puisne; and l&e g^tiie jaice^ 



orie acid, does not always destroy the bacilli 
after they have been liberated in the stomach. If "they enter the intes- 
tines in a living condition, they mar easily penetrate "the walk of die 
viscera and invade the mesenteric glands and other organs of the 
The milk of tubercular cows is more dangerous than the flesh, bat if 
such milk be dilated with from forty to one hundred parts of healthy 
milk, it* virulence is destroyed. It is probable that among human 
i oercular mother can transmit the infection to 
the infant, but this is not positively demonstrated. 

Though it is possible to introduce the infection through the alhnenta ry 
canal, by far the most common mode of infection is through the respira- 
bacilli are contained principally in the sputa, but 
they also exist in the saliva of tubercular patients. In this war the 
contec 1 Though it may pass through the mucous 

membranes of the bod sot penetrate the skin unless ther- 

previous solution introduction of the con- 

tagior J manifestation may occur in any part of the body. It 

freqs omes thus ap p ar e n t at the seat of an injury or other acci- 

dental lea 

The ar parasite can be transmitted from a tubercular parent 

inborn : s not infrequently observed among certain 

of the lower aniniaLs. and it is also possible in the human species. In 
this plained the numerous deaths from tuberculosis among 

the newborn children of tubercular parents, though in many instances 
undoubtedly the disease is acquired feebled infant after birth. 

When tuberculosis has been thus derived before birth, the liver is the 
pal seat of the infective process, since the bacilli hare entered 
that organ through the avenue of the umbilical vein. It is not yet pos- 
sible, hov. state with any degree of accuracy the freque: 
such a mode of infection. 

Tubercular lesions present themselves in two principal forms : either 
: ate jpro s, which can be most e :!y examined upon 

the serous surfaces of the body, or in the form of rounded gray masse*. 
of the size of a pea or larger, which are infiltrated into the tissues. 
Besides these ordinary forms are numerous lesions of a different ehar- 
which. I now re. . *s tuberculous, since their 

pendent upon the presence of the tubercle bacilli. Many 
scrofulous diseases, chronic abscesses, varieties of lupus, articular and 
serous inflammations are now classified among the tubercular diseases. 
characteristic histological feature of the tubercular process con- 
sists in the de f elementary t, which may originate 
in any tissue of the body. They consist, for the most part, of giant 

which in their turn &- - assed by a zone of small embr 

cells. These cellular ascular, since the capillary 

vessels which have originally permeated the locality become oblit- 
and disappear. 

Th- -nay be formed in any part of the 

which tubercle bacilli have found access. These paras 
the r passages and fix themselves in the walls of the alveoli. 

ral circulation of the bod; y become 



158 PARASITIC AND INFECTIVE DISEASES. 

lodged in the spleen, or in the liver, or elsewhere. At the point where 
they become stationary, under the influence of their poisonous secre- 
tions the nuclei of the adjacent cells begin to divide. In consequence 
of the irritation thus excited, an immigration of leucocytes is set up. 
The bacilli become surrounded by proliferating cells, of which some 
become enormously enlarged through the growth of their protoplasm, 
and by the subdivision and multiplication of their nuclei. These con- 
stitute the central giant cells, around which smaller epithelioid cells are 
grouped, while the outlying periphery of the irritated region is occupied 
by small, round, embryonic cells. The capillaries disappear by reason 
of the coagulation of their contents and the pressure that is exercised 
upon their walls. 

The gray granulations of tuberculosis (miliary tubercles) are formed 
by the aggregation of a number of elementary tubercles. The larger 
tubercular masses are in like manner composed of numerous elementary 
tubercles, but the central portion of the mass is in a condition of caseous 
degeneration. The tissue is said to be in a condition of tubercular infil- 
tration when it is filled with confluent granulations, constituting gray 
infiltration, or with caseous tubercles that constitute the yellow or 
caseous variety of infiltration. 

The process of caseation is dependent upon the obliteration of the 
vascular structure of a tubercular mass. The central portions undergo 
a vitreous degeneration, which is succeeded by caseous or fatty degenera- 
tion of the necrotic cells. These cheesy masses themselves may undergo 
infection with pyogenic bacteria if they communicate with the external 
atmosphere. Under the influence of these organisms suppuration 
occurs, and the cheesy mass becomes softened, dissolved, and evacu- 
ated, or removed by absorption. When such infection does not occur, 
it sometimes happens that the tubercle becomes imperfectly organized. 
It is transformed into a little, hard nodule, composed of a meshwork 
of fibrous tissue, in which may be discovered the remains of atrophied 
cells. Capillary vessels make their appearance in the surrounding zone 
of embryonic cells, among which giant cells that have escaped com- 
pression and atrophy may be still discovered. Occasionally the tuber- 
cular mass becomes infiltrated with calcareous salts, or with a deposit 
of pigment. 

It has been shown experimentally that irritation of the tissues by the 
intrusion of various inanimate bodies, like cantharides, lycopodium, 
Cayenne pepper, etc., produce various lesions that in their general appear- 
ance and histological structure closely resemble the lesions of genuine 
tuberculosis ; but this pseudo-tuberculosis is non-infective, and does not 
contain the tubercle bacillus, consequently it cannot be transmitted to 
other animals, nor does it produce general infection of the organism. 

In the lower animals analogous pseudo-tubercular lesions are pro- 
duced through the invasion of the tissues by certain minute verminous 
parasites. The eggs, or the little worms themselves, become encysted 
in a pseudo-tubercular mass composed of giaut cells, epithelial cells, 
and embryonic cells. Sometimes the parasitic ovum or embryo is con 
tained within the protoplasm of a giant cell. 

Other microorganisms besides the tubercle bacillus possess the- 



SCROFULA. 159 

power of exciting a process analogous to that of tuberculosis. They 
may be inoculated into the bodies of certain lower animals, where they 
proliferate and produce pseudo-tubercular granulations, from which the 
contagion may be conveyed by inoculation to other animals. It is 
probable that the progress of investigation will furnish numerous 
examples of similar infection. In like manner the invasion of animal 
tissues by various mycotic growths may produce lesions and symptoms 
not unlike those of tuberculosis. Witness the process of actinomycosis. 
Certain varieties of aspergillus may also act upon the tissues in a similar 
infective manner. 

It is thus rendered apparent that the tubercular lesion possesses 
nothing characteristic but the specific parasite by which it is caused. 

The tubercular process occurs most frequently in the lungs ; after 
those organs follow the larynx, the intestines, and the uro-genital organs. 
In the following sections the various forms of tuberculosis that fall 
under the observation of the physician will be successively considered. 
Before undertaking this survey a few paragraphs must be devoted to 
that predisposition or diathesis by which the invasion of tubercular dis- 
ease is facilitated. 

Scrofula. 

Scrofula is a term formerly used to designate a great number of 
external diseases of the cutaneous surface, together with many internal 
disorders of the lymphatic apparatus and other viscera, which are now 
referred either to tubercular infection or to syphilis as their cause. The 
word scrofula is now retained only for the purpose of designating that 
predisposition or diathesis which favors the occurrence of tubercular 
infection. The existence of the scrofulous diathesis is most conspicuous 
in early childhood. It is characterized by a peculiar susceptibility to 
inflammatory processes, and by imperfect resolution of such inflamma- 
tions when once established. Hence the peculiar turgescence of the 
upper lip and nose that is so characteristic a feature in the physiog- 
nomy of snuffling, scrofulous persons ; a turgescence that is maintained 
by a stagnant condition of the lymphatic circulation. 

The ultimate cause of the scrofulous diathesis is not yet fully under- 
stood. It is known, however, that various antecedent conditions favor 
its manifestation. Of these, heredity is a very potent influence. The 
children of scrofulous, tuberculous, and arthritic parents are very liable 
to exhibit the scrofulous diathesis. The children of elderly, feeble, 
syphilitic, unequally mated, and cachectic parents are frequently 
scrofulous. 

The scrofulous diathesis may be acquired through errors of nutrition, 
when young children are brought up by hand, or are nourished with 
improper food after the period of lactation is past. These unwhole- 
some conditions may result in the evolution of rickets, or they may 
produce the scrofulous diathesis ; and it is not yet known why these 
different results should follow apparently identical causes. 

The development of scrofula is not uncommon during the period of 
life between the first and second dentitions, when children are confined 



160 PARASITIC AXD INFECTIVE DISEASES. 

in unwholesome, ill-ventilated, damp, and sunless apartments ; the 
diathesis is, therefore, one of the common misfortunes of poverty and 
neglect. 

Scrofula frequently results from the persistent use of a diet in which 
the proper proportion between nitrogenous food and the ternary com- 
pounds is not observed. When the normal proportion of one part of 
nitrogenous matter to five parts of the carbohydrates is disregarded, 
the scrofulous diathesis is rapidly created. When this diathesis exists, 
it is a notable fact that the perspiration and the stools of the patient 
are excessively acid, and that oxalic acid and the urates frequently 
appear in the urinary sediment. The contents of the intestinal canal 
are excessively acid, and the bones are deficient in mineral constituents. 
These facts indicate a perversion and impediment of the processes of 
oxidation that should be conducted in the tissues as a necessary condi- 
tion for healthy nutrition. In this connection it is worthy of note that 
active exercise in the open air, and everything that favors oxidation 
and healthy nutrition, are opposed to the manifestation and progress of 
scrofulous phenomena. 

In these errors of nutrition there are many points of resemblance 
between the scrofulous diathesis and the arthritic predisposition. Both 
classes of children exhibit the same tendency to obstinate catarrhal in- 
flammations ; and scrofulous patients who, under favorable circum- 
stances, have been cured in childhood, not unfrequently manifest 
arthritic symptoms in later life. The exact nature of the difference 
between the two diatheses is unknown. The points of resemblance 
consist in similar errors of assimilation and nutrition. 

In the treatment of scrofula it is necessary to aid the nutritive 
processes, and to promote tissue metamorphosis. In scrofulous families 

the marriage of scrofulous individuals should be discouraged. During 

© © _ © 

the period of pregnancy the health of the mother and her nutritive 
processes should be carefully supervised, and during the period of lac- 
tation every effort should be made to procure for a scrofulous infant the 
benefit of a healthy wet-nurse. After the period of weaning, the state 

of the digestive organs should receive constant attention. Excessive 
© © 

acidity should be prevented, and a healthy state of the gastro-intestinal 
secretions must be maintained. Alcohol, tea, coffee, and tobacco must 
be rigidly proscribed, since they are not tolerated by scrofulous or 
arthritic patients. Alkaline salts, rhubarb, and the astringent and 
bitter tonics are often of great service. The syrup of the iodide of 
iron and other preparations of iodine, iron, and tannin are among the 
most useful of internal remedies. A dry, moderately warm, and bracing 
climate is preferable to a damp and chilly residence in any quarter of 
the world. The patient should be advised to seek, if possible, a home 
where active exercise in the open air can be enjoyed during every day 
of the year. The clothing should be of a character to equalize the 
temperature of the body at all seasons of the year. The skin should 
be rendered resistant to cold by daily salt sponge baths, and by liberal 
friction with the flesh-brush. Cod-liver oil is exceedingly useful as a 

remedial agent and as an article of nutriment. It should be given in 

© © 

teaspoonful doses shortly after each meal. Its administration should be 



PULMONARY CONSUMPTION — PHTHISIS PULMONUM. 161 

continued for many months, or even for years. Its taste may be effi- 
ciently covered by giving it in the form of an emulsion with maltine, 
or with pancreatized extract of beef, or, best of all, with fermented 
milk in the preparation known as matzol. 



Pulmonary Consumption — Phthisis Pulmonum. 

Etiology. It has been estimated that about one-seventh of the 
total mortality is due to pulmonary consumption. About two-thirds of 
the deaths from chronic disease are due to this cause. 

Pulmonary tuberculosis is of either primary or secondary origin. In 
the primary form of the disease the contagion enters the lungs from 
without, and the consequences of infection may be restricted to the 
respiratory organs, while in the secondary form the contagion enters 
the pulmonary apparatus from some other portion of the body which 
had been previously infected. 

The nature of the contagion, and the manner in which it may be 
transmitted from one animal or individual to another has been already 
considered. There remains for discussion the influence of predisposing 
causes and favoring conditions that determine the incidence of tuber- 
cular disease. Among these influences the constitutional condition of 
the patient is preeminent. Anaemic, weakly, and unhealthy persons 
are particularly liable to the invasion of tuberculosis. Their tissues 
possess little power of resistance to the entrance of the parasite. Such 
constitutional weakness may be either inherited from feeble parents 
who were themselves the victims of syphilis, cancer, or other chronic 
disease, or it may be an acquired predisposition. The offspring of 
elderly people are also more liable than others to become the victims 
of pulmonary disease. 

An originally healthy organism may become undermined by starva- 
tion, or by exposure to bodily and mental causes of exhaustion and 
disease. In this way consumption may successfully invade a patient 
who has been exhausted by dissipation, poverty, anaemia, and defective 
nutrition or wasting discharges. Inflammatory diseases of the respira- 
tory organs often afford an opportunity for the entrance of the tubercle 
bacillus. Pulmonary consumption is frequently observed after catarrhal 
bronchitis or inflammation of the lungs. It sometimes follows an 
attack of serous pleurisy, though in such cases the pleurisy may be the 
consequence of previous tubercular infection. The inhalation of dust, 
especially in the form of irritating particles of a metallic or mineral 
character, such as certain artisans are compelled to inhale, is a common 
predisposing cause of pulmonary tuberculosis. Wounds and injuries 
of every kind that involve the thorax and its contents are liable to be 
followed by tuberculosis. 

The mortality from consumption is, among children, greatest between 
the fifth and tenth years of life ; and it exhibits a steady increase with 
every advance in age. Both sexes are about equally liable to the dis- 
ease, though in some countries the mortality is greater among one sex 
than among the other — a fact that is probably controlled by habits of 

11 



162 PARASITIC AND INFECTIVE DISEASES. 

life and the relative degree of confinement in crowded and ill-ventilated 
habitations. The great influence of this cause is shown by the fact 
that pulmonary consumption is preeminently a disease that accompa- 
nies poverty. It is common among artisans, mechanics, and sewing- 
women who labor in close and ill-ventilated factories. It frequently 
occurs in prisons, almshouses, and other institutions where the inmates 
are confined within narrow limits. Climatic influences are less impor- 
tant than the degree of elevation above the sea-level ; though a dry, 
cool, bracing, equable climate is undoubtedly more favorable to health 
than one that is damp, warm, and variable. Above the level of 2000 
feet pulmonary consumption rarely occurs, and the inhabitants of such 
elevated regions not unfrequently become rapidly consumptive if they 
migrate to a lower level. It is doubtful whether racial peculiarities 
exert any very conspicuous influence that can be compared with the 
habits of life and the environment of the individual. 

It was formerly supposed that malarial diseases, cancer, and many 
other maladies were incompatible with the development of pulmonary 
consumption, but this opinion has proved to be erroneous. 

Symptoms. Pulmonary consumption usually develops in a very 
tardy and insidious manner, so that the diagnosis may be for a long 
time exceedingly doubtful. In many instances the disease originates 
in chlorosis; such cases, if females, often exhibit disorders of men- 
struation. The presence of scrofulous indications of hereditary predis- 
position to pulmonary disease should awaken suspicion, especially if the 
ordinary treatment of anaemia should prove ineffectual. Sometimes 
the earliest symptoms of consumption are confined to an inexplicable 
loss of appetite and power of assimilation, accompanied by a tendency 
to apparently causeless paroxysms of fever. In other cases the symp- 
toms of gastro-intestinal catarrh alone attract attention, until at last 
the lungs are evidently involved. 

Sometimes the catarrhal symptoms are manifested in the larynx and 
other respiratory mucous membranes. In such cases the evidences of 
catarrh become more and more evident at the apices of the lungs, and, 
finally, unmistakable evidence of infiltration can be discovered. A ten- 
dency to repeated haemoptysis forms another early symptom of con- 
sumption which may be sometimes observed for years before the final 
demonstration of actual tuberculosis. 

The occurrence of pneumonia in feeble and debilitated patients is 
often observed as a preliminary step toward pulmonary disease. Especi- 
ally unfavorable is the presence of inflammation in the upper lobes of 
the lungs. In like manner the existence of a dry pleurisy in the upper 
portion of the thorax, and tedious or insidious effusions of a serous 
character into the pleural cavities, are frequently dependent upon a 
latent tubercular process. In other cases the occurrence of tuberculosis 
in the bones, joints, rectum, or uro-genital apparatus is accompanied by 
a simultaneous or secondary development of the disease in the lungs. 

The existence of an hereditary or congenital predisposition to con- 
sumption is frequently indicated by the physical conformation of the 
body. So characteristic are the appearances which indicate this ten- 
dency that they can scarcely fail to be detected by the practised eye. 



PULMONARY CONSUMPTION — PHTHISIS PULMONUM 



163 



The patient is usually tall and slender, with a long and graceful neck ; 
the skin is thin, delicate, and pale ; the muscles are small and flabby ; 
the bones are light, and the skeleton is slightly constructed ; the hair 
is usually fine and silky ; the eyes are sunken and surrounded with 
dark circles ; the sclerotic coat is of an extraordinary bluish whiteness, 
like that of skimmed milk ; the cheeks are hollow ; the bones of the 
face are prominent ; the whiteness of the teeth matches that of the eye- 
balls, and they are disposed to early decay. (Fig. 78.) The thorax is 



Fig. 71 




Pulmonary consumption. (Rush Medical College Clinic.) 



usually long and flat, the intercostal spaces are consequently broad and 
deep ; the articulation between the manubrium and the body of the 
sternum is exceedingly prominent; the supra- and infra- clavicular 
fossae are unusually depressed, in consequence of the absence of subcu- 
taneous fat, and the lack of muscular volume ; the shoulders hang 
forward, and there is a marked disposition to assume a stooping posture; 
the scapulae project like rudimentary wings from the dorsal surface of 
the body ; the extremities of the fingers are often bulbous, and the 
nails are incurved, like claws, by reason of the absorption of the sub- 
cutaneous fat. 

The vasomotor nervous system is usually very excitable in consump- 
tive patients. They blush easily, and a slight febrile movement is 
sufficient to produce a brilliant flush upon the cheeks, constituting the 
well-known hectic flush that is so conspicuous during the evening 



164 PAKASITIC AND INFECTIVE DISEASES. 

hours. Sometimes this appears only upon the side of the face that 
corresponds to the affected portion of the lungs. 

In many cases the existence of a characteristic cachexia is indicated 
by the appearance of brown patches in the skin of the forehead or upper 
portion of the cheeks (chloasma phthisicorum). A similar pigmenta- 
tion of the skin is sometimes diffused quite generally over the surface 
of the body. It has been asserted that in these cases the spleen and 
the lymph glands are extensively diseased, and that haemoptysis rarely 
occurs. This pigmentation of the skin must not be confounded with 
the patches of pityriasis versicolor that sometimes develop upon the 
surface of the thorax as a consequence of the growth of the parasite 
microspor on furfur. These vegetations, and others of a similar nature, 
are favored by the occurrence of copious perspiration which is so often 
a prominent feature in the hectic fever of consumption. For the same 
reason eruptions of miliaria or sudamina are frequently observed. 

The cause of phthisical sweating is not well understood. The symp- 
tom is frequently connected with fever, but it often occurs without any 
previous febrile movement. It is usually experienced during the night, 
especially during the early morning hours, and is often accompanied by 
a disagreeable odor that is due to the presence of various fatty acids. 
Occasionally the perspiration is limited to one-half of the body, and 
prevails upon the side that corresponds to the affected lung. 

The course of the disease is usually characterized by great loss of flesh 
and weight. The fat is absorbed from every part of the body, and all 
the tissues become pale and anaemic. But sometimes, in spite of ad- 
vanced pulmonary disease, subcutaneous fat may be preserved in con- 
siderable amount. During the latest stage of the disease the lower 
extremities frequently become oedematous, either as a consequence of 
complicating nephritis, or as the simple result of anaemia and cachexia. 
Occasionally it is conditioned by the formation of thrombi in the veins. 
Sometimes bedsores are developed over the points of greatest pressure, 
when the patient has been confined long in bed. There is great differ- 
ence in the duration of such confinement ; some patients are able to get 
up, and to occupy themselves in various ways until the latest period of 
the disease is reached, while others are compelled to remain in bed for 
months, or even for years before they are released by death. The 
position that is assumed by the recumbent sufferer depends very much 
upon the respiratory capacity of the remaining portions of the lungs. 
Dyspnoea compels an attitude with the head and shoulders elevated. 
The existence of pleurisy generally renders it necessary to lie upon the 
comparatively healthy side, since pressure upon the inflamed portions 
of the pleural membrane causes pain. 

The intellectual faculties usually remain unclouded to the last. 
Sometimes the action of the brain is remarkably clear and vigorous. 
The patient continues bright, cheerful, and hopeful with regard to the 
future. Delirium rarely occurs except in the latest stage of the 
disease. 

Pulmonary consumption is almost always accompanied by fever. 
Sometimes the febrile .movement is very slight, but when purulent 
cavities have formed in the lungs, and the products of suppuration are 



PULMONARY CONSUMPTION — PHTHISIS PULMOXL'M. 165 

absorbed into the general circulation, the symptoms of hectic fever often 
become very marked. The fever usually rises during the afternoon 
and evening, but sometimes the highest temperature is observed in the 
morning. Persistent fever usually occurs in cases of quick consump- 
tion. The pulse is generally rapid and feeble, but exhibits no charac- 
teristic peculiarities. 

In many cases the progress of the disease is so gradual, and the 
necessities of the organism are so completely adjusted to the situation, 
that dyspnoea is not experienced. But, when acute bronchitis or high 
fever complicates the disease, the difficulty of respiration may become 
very pronounced. 

The local changes that take place in the lungs usually commence in 
their upper portions, and are sometimes restricted to the apices. It is 
supposed that the tubercle bacilli find in these regions the most favora- 
ble situation for their multiplication, since the upper part of the thorax 
is less movable than its other portions, so that the circulation of air and 
of blood is comparatively sluggish in the pulmonary apices. Among the 
earliest symptoms of disease in these localities are circumscribed catarrh 
of the bronchi, rough and interrupted vesicular respiration, prolonga- 
tion of the expiratory sound, and a notable difference between the 
respiratory murmurs upon the two sides of the thorax. Sometimes a 
sibilant rale or other moist rales can be distinctly heard, especially at 
the end of a deep inspiratory movement. Associated with these symp- 
toms may be often observed a diminution in the extent of the respira- 
tory movements. If this be not always visible, it may be frequently 
detected by laying the palm of the hand over the upper part of the 
thorax. Any considerable disease of the upper portion of the lung is 
attended by its retraction and by corresponding depression of the 
thoracic wall. Such collapse is often very conspicuous on inspection. 
Especially significant is the existence of a considerable difference be- 
tween the two sides of the thorax. Percussion over the region of 
depression will then indicate a certain amount of dulness, of which the 
extent and intensity corresponds with the amount of infiltration that 
has taken place. It must not be forgotten, however, that on account 
of the larger development of the right pectoral muscle a greater degree 
of dulness is often perceptible below the right clavicle than below the 
left. 

Infiltration of the pulmonary tissue is indicated by increased vocal 
fremitus, dulness on percussion, bronchial breathing, bronchophony, 
and. bronchial rales. When caseous masses have softened and have 
broken down into cavernous hollows, the physical signs will depend 
upon the condition and location of the cavity or cavities that are thus 
formed. The symptoms are most conspicuous when a cavern occupies 
a portion of the lung near its external surface. If such a cavity be 
filled with purulent liquid, it yields a dull sound on percussion, but 
when it is occupied chiefly by atmospheric air, percussion elicits a 
resonant sound, which assumes a tympanitic character if the diameter 
of the cavern is not less than two or three inches. When the cavern 
communicates freely with the external air. a cracked-pot sound may be 
easily elicited on percussion while the mouth of the patient is open. 



166 



PARASITIC AXD INFECTIVE DISEASES. 



Vocal fremitus and bronchophony are under such circumstances in- 
creased. Occasionally a succussion sound may be elicited by shaking 
the patient, and a sound like that of dropping water can sometimes be 
heard. These phenomena only occur when air and liquid are both 
present in the cavern. 

The character of the sputa possesses greater significance in pulmo- 
nary consumption than in any other disease of the lungs, since the 
demonstration of tubercle bacilli affords the means of a positive diag- 
nosis. But it sometimes happens that the bacilli may be for a con- 
siderable time absent from the sputa in undoubtedly phthisical cases, 
because the infiltrated mass in which they are contained has not yet 
broken down and contributed anything to the expectoration. The 
number of bacilli in the sputa is subject to great variations from day to 
day, but generally the more acute the tubercular process in the lungs, 
the greater their number in the expectoration. 

Careful observation of the sputa sometimes results in the discovery 
of delicate elastic fibres derived from the pulmonary tissue (Fig. 79 )* 



Fig. 7< 




; _. 









- " - ' ■ x - 

n 



Elastic fibres of lung tissue obtained from sputa after digestion in caustic soda. 
(Drawn by Dr. Johx Wilson.) 



These are less conspicuous than the fragments of pulmonary substance 
that are expectorated during the course of gangrene and abscess of the 
lung. Degenerated epithelial cells from the alveolar passages are very 
frequently present, but their diagnostic significance possesses compara- 
tively little importance. Occasionally small calcareous masses are 
voided in the sputa. These sometimes are derived from bronchial 
glands that have undergone calcareous degeneration ; and in other 
cases they represent a similar process in the pulmonary tissue itself. 
When disease of the spine or of the ribs complicates the case, osseous 
fragments may occasionally find their way into the sputa. 

The form and general appearance of the sputum manifest consider- 
able variability. At first the slimy and transparent mass closely 
resembles the ordinary sputum of bronchitis. Sometimes it assumes a 
jelly-like appearance, and if pneumonic inflammation of a chronic 
character complicates the tubercular process, the expectorated matters 
exhibit a greenish tinge. When suppuration commences in the pul- 



PULMONARY CONSUMPTION — PHTHISIS PULMONUM. 167 

monary substance the sputa contain more or less pus, and when a cavern 
is formed in the lungs its contents are frequently discharged in the 
form of rounded spheres or partially flattened discs. When associated 
with numerous air-bubbles in the expectoration, these masses float in 
water, but when freed from such support, they rapidly sink to the 
bottom of the vessel into which they have been discharged. 

The amount and the character of the cough by which expectoration 
is accomplished depend largely upon the extent to which the bronchi 
are involved in the disease. In some cases cough is scarcely noticeable, 
while in others a copious discharge into the bronchi excites irritation 
and harassing efforts for the discharge of sputa. 

The heart is frequently disturbed by the course of pulmonary con- 
sumption. Obstruction to the passage of blood through the pulmonary 
artery causes an accentuation of the diastolic sound at the entrance of 
the artery, and a metallic resonance is imparted to the cardiac sounds 
if large caverns form in the immediate vicinity of the organ. Occa- 
sionally the heart may be displaced by retraction of the pulmonary 
substance. 

The urine exhibits no uniform or characteristic changes. It is 
usually diminished in quantity, and its constituents are in like manner 
generally reduced. In advanced cases traces of albumin are frequently 
present ; and occasionally sugar may be discovered. 

The complications of pulmonary consumption are exceedingly 
numerous, since every organ and tissue suffers in structure and func- 
tion, either directly from secondary infection, or indirectly from lack of 
nutrition. 

Lupus sometimes develops upon the skin. The bones become in- 
vaded by the tubercular process. The joints are not unfrequently 
attacked by an inflammation that owes its characteristic course and 
pathological appearances to the tubercular infection. In advanced 
cases of consumption the muscles frequently exhibit an exaggerated 
irritability. A sudden tap upon the biceps, or other conspicuous mus- 
cle, is immediately followed by a local swelling of the muscular fibres 
which persists for a number of seconds. This appearance is not pecu- 
liar to consumption alone, though it is frequently exhibited most 
prominently upon the side of the body that corresponds to the affected 
lung. In certain cases a peristaltic wave may be seen to traverse the 
extent of the muscle from the point where it was tapped to its extremi- 
ties. This phenomenon is also observed in other conditions of general 
prostration, anaemia, and innutrition. 

The peripheral lymph glands sometimes undergo tubercular inflam- 
mation at the same time that the lungs are invaded. They are liable 
to suppuration followed by the formation of chronic fistulous openings 
through the external surface. 

In many cases the larynx becomes involved in the disease. The 
actual existence of laryngeal tuberculosis is often preceded by hoarse- 
ness and difficulty of articulation, that are dependent upon enfeeble- 
ment and more or less complete paralysis of the laryngeal nerves 
and muscles. Similar inflammatory processes are often developed in 
the trachea and bronchi. The occurrence of haemoptysis as an early 



168 PARASITIC AND INFECTIVE DISEASES. 

symptom of pulmonary consumption has been already noted, but the 
presence of a bloody stain in the expectoration does not necessarily con- 
demn the patient to consumption, unless the characteristic bacilli are 
also present. In such cases the bloody discharge proceeds from a 
capillary oozing into the alveolar passages. Of a different character is 
the haemoptysis that occurs at an advanced stage in the course of the 
disease, through the formation of caverns in whose walls the rupture of 
aneurismal dilatations gives origin to a copious flow of arterial blood. 
The frequency of such an event, however, is not so great as it has been 
ordinarily estimated. Haemoptysis occurs in scarcely 25 per cent, of 
the cases of pulmonary tuberculosis. 

The act of expectoration is attended with considerable difficulty at 
the commencement of the disease ; but as it advances, and the lungs 
become more extensively invaded, sputa are discharged with less diffi- 
culty. G-angrene of the lungs rarely occurs, though if for any reason 
the sputa are retained in the air-passages, they soon exhale a fetid 
odor. 

The occurrence of pleurisy as a complication of pulmonary con- 
sumption is a very common event. It may exhibit all the different 
varieties of the disease ; it is liable to remissions and exacerbations, 
and is sometimes quite transient in its duration. Pneumothorax is a 
much more rare event. 

Pericarditis is one of the rarer complications of consumption. It is 
sometimes of tubercular character. Thrombi sometimes form in the 
heart, or in the pulmonary arteries and veins, leading to the occurrence 
of peripheral embolism in the arterial system. 

Digestive disorders are exceedingly common. In many cases these 
are accompanied by loss of appetite and an unconquerable aversion to 
food, a fact that renders doubly difficult the treatment of the patient. 
Sometimes obstinate vomiting or diarrhoea are present, which appear 
to be of a functional character. In advanced cases of disease the weak- 
ness of the muscular coats of the alimentary canal, and the deficiency 
of hydrochloric acid in the gastric juice, may account for a large por- 
tion of the digestive disturbances that exist. In many cases a catarrhal 
stomatitis adds to the discomfort of the patient, and sometimes aphthous 
ulcerations exist in the mouth. Numerous parasites, under such cir- 
cumstances, proliferate in the oral cavity if great care be not taken for 
its proper cleansing and disinfection. Tuberculous ulcers occasionally 
form upon the tongue, but they are more frequent in the throat, where 
they often excite great pain and difficulty in swallowing. 

The function of the intestines is frequently disordered. Alternate 
constipation and diarrhoea occur during the early stages of the disease ; 
and when in its later course tubercular ulcerations or amyloid degenera- 
tion have invaded the intestinal tract, obstinate diarrhoea persists until 
the close of life. These disorders are sometimes unattended by any 
considerable pain, but in other cases they are accompanied by great 
distress. The favorite seat of ulceration is in the right iliac fossa. 
Sometimes fragments of necrotic tissue may be discovered in the stools, 
and in certain cases there may be extensive ulceration, though the 
bowels remain constipated. Hemorrhage from such ulcers rarely 



PULMONARY CONSUMPTION — PHTHISIS PULMONUM. 169 

occur, since the gradual development of the process is attended by 
occlusion and obliteration of the neighboring vessels. Bleeding is for 
this reason more liable to occur from the surface of small and recent 
ulcerations. In many cases the existence of a small intestinal ulcer 
leads to peritonitis, either through the extension of the inflammation to 
the peritoneum, or by reason of perforation of the intestinal wall. The 
occurrence of rectal fistula is generally dependent upon a tubercular 
process. Not without some degree of justification was the opinion of 
the older physicians that the cure of such a fistula was liable to be 
followed by a transfer of the disease from the rectum to the lungs. 

The liver is sometimes enlarged, and may undergo fatty degeneration, 
amyloid degeneration, or passive hyperemia from stagnation of the 
blood current. Similar enlargements of the spleen are not uncommon, 
though it is sometimes enlarged by infiltration with caseous masses. 

In the male sex tubercular inflammation and caseous degeneration 
are not uncommon in the testicle and epididymis, where the deposit may 
be recognized in the form of hard and irregular masses. Sexual 
appetite frequently remains active, though the general health and vigor 
of the patient be greatly depressed. Among women, early disorder 
of menstruation is often manifested. The menses are scanty, irregu- 
lar, and finally suppressed. The occurrence of pregnancy is usually 
accompanied by great increase in the activity of the disease. 

The urine frequently contains albumin, which, when present in small 
quantities, merely indicates the existence of cachexia ; but in actual 
renal disease, casts and a considerable amount of albumin may be dis- 
covered. Sometimes the urine contains pus which is derived from 
tubercular abscesses in the course of the urinary tract. 

The occurrence of the symptoms of nervous disturbance adds greatly 
to the unfavorable character of the prognosis, since tubercular menin- 
gitis or suppurative meningitis sometimes exists as a consequence of an 
extension of the tubercular process to the membranes of the brain. 

In certain cases there is great complaint of pain, which may be 
caused either by pleurisy or by muscular soreness. These muscular 
pains are sometimes excited by over-exertion in the act of coughing, 
but they are sometimes intermittent, and apparently dependent upon 
peripheral neuritis involving the muscular branches of the nerves. 

Insomnia is a not uncommon incident in the course of pulmonary 
consumption, even though the cough be very trifling and not troublesome 
at night. 

Pulmonary tuberculosis is a chronic disease. According to the 
statistics collected by Williams, the average duration of life after the 
commencement of the disease is seven and a half years. Sometimes, 
however, the process is completed in a few weeks. Such cases con- 
stitute what is termed quick consumption. They are most frequently 
observed among young people. Sometimes a chronic case suddenly 
assumes an acutely progressive character that leads rapidly to a fatal 
termination. This result is sometimes dependent upon the intercur- 
rence of an acute pneumonia or other extensive and violent form of 
inflammation, but it is not unfrequently consequent upon the occurrence 



170 PARASITIC AND INFECTIVE DISEASES. 

of acute miliary tuberculosis that becomes generally diffused throughout 
the organs of the body. 

That consumption is not invariably fatal has been repeatedly shown 
by the results of post-mortem examination of the lungs of persons who 
have died of other diseases, after having manifested, many years pre- 
viously, the symptoms of pulmonary tuberculosis. In such cases the 
seat of former disease is indicated by retraction of the pulmonary sub- 
stance, and the existence of cicatricial tissue that frequently contains a 
calcareous nodule at its centre. In such cases the healing process had 
been complete, but in many instances only partial recovery occurs, or 
complete recovery is followed by fresh infection in other portions of the 
organism, so that the patient remains a chronic invalid. 

In fatal cases death may result from gradual exhaustion, or it may 
occur suddenly from violent haemoptysis, or from oedema of the glottis. 
Sometimes death results from slow starvation, caused by the difficulty 
of swallowing, or by the impossibility of digestion and absorption. 
Death may also result from various complications within the thorax, 
producing dyspnoea and suffocation. Sometimes it is consequent upon 
embolism or thrombosis. Occasionally it is preceded by the symptoms 
of general anasarca. In a certain number of cases, however, death 
occurs without any other apparent cause than complete exhaustion of 
the nervous system. 

Pathological Anatomy. The most characteristic pathological ap- 
pearance in the lungs is furnished by the presence of cheesy masses in 
the lung tissue, which are produced by caseous degeneration of the 
products of inflammation that has been excited by the secretions of the 
parasitic bacilli. These microorganisms are most abundant in the recent 
products of exudation, though their spores are numerous in old caseous 
masses where the bacilli themselves are seldom found. Occasionally an 
entire lobe of the lung is infiltrated with a cheesy, tubercular mass, but 
generally the caseous deposits are lobular in their dimensions, and are 
separated from one another by indurated, slate-colored septa of inflamed 
connective tissue. The single lobular infiltrations scarcely exceed the 
size of a pin's head, but by their fusion large and homogeneous masses 
of degenerated tubercular deposit are formed. Such caseous masses 
may undergo calcareous infiltration, and by a species of capsulation the 
chalky deposit becomes isolated from the remaining lung tissue, and 
may thus exist indefinitely without doing any harm. But frequently a 
suppurative process is set up around the concretion, which is finally 
loosened from its bed, and is discharged with the sputa. When such 
calcareous infiltration does not take place, the cheesy mass is usually 
softened by the occurrence of suppuration about its periphery. The 
deposit is invaded by pyogenic bacteria, and is finally dissolved and 
removed with the contents of the abscess that is thus produced. In 
this way pulmonary caverns are developed. Their contents are gen- 
erally evacuated into an adjacent bronchial tube. Such cavities 
frequently coalesce, and gradually work their way toward the periphery; 
occasionally they rupture into the pleural cavity or into the pericardium, 
unless their progress is restricted by the formation of a zone of chronic 
pneumonia in the connective tissue that surrounds the cavity. Old 



PULMONARY CONSUMPTION — PHTHISIS PULMONUM. 171 

caverns are frequently lined by a smooth surface that sometimes puts 
forth granulations that contract and finally accomplish the obliteration 
of the cavity. 

The pulmonary bloodvessels which are exposed in the formation of 
such cavities exhibit a remarkable degree of resistance to the necrotic 
process. It is not unusual to see large bloodvessels lying exposed in a 
cavern of considerable size, sometimes crossing independently from one 
side to the other without any support whatever. The walls of a vomica 
usually exhibit large bloodvessels, partially exposed and projecting into 
the vacant space. Sometimes such vessels exhibit aneurismal dilata- 
tions which, by their rupture, occasion the profuse and dangerous 
hemorrhages that are experienced during the later stages of consump- 
tion. 

The bronchi sometimes become excessively dilated, forming cavities 
that in many respects resemble the caverns that are formed by erosions 
of the pulmonary substance. Such dilatations may be recognized by 
their epithelial lining, and by their continuity with a bronchus which 
may be followed into the dilated space. 

In the vicinity of caseous deposits, minute tubercles may be frequently 
discovered in the course of the lymphatic vessels, constituting a local 
deposit in the vicinity of older infiltrations. In other cases similar 
miliary tubercles are universally disseminated throughout the lungs and 
other organs of the body. 

Besides the changes that exist in the lungs pleuritic inflammation is 
usually observed. This may be limited to the upper portion of the 
lungs, or it may extend to the whole pulmonary membrane. 

There has been much discussion regarding the origin of the tuber- 
cular process in the lungs. Some authors have maintained that it com- 
mences within the minute bronchi, while others insist that it originates 
within the alveolar passages and air cells. Others again defend the 
inter-alveolar origin of the disease. It is probable, however, that the 
process being dependent upon an invasion by the tubercle bacillus, the 
point of commencement of parasitic activity is determined by the mode 
of its introduction. When the contagion enters the lungs by inspira- 
tion, the favorite seat of the tubercular process is found in the walls of 
the terminal bronchioles and alveolar passages. But when the con- 
tagion enters the lungs from other organs of the body, the bacilli will 
be found in the inter-alveolar spaces and in the lymph and bloodvessels. 
When the walls of the bloodvessels are attacked by the infective bacilli, 
hemorrhagic oozing takes place, and the phenomenon of early haemop- 
tysis is witnessed. When the air cells are first invaded, the symptoms 
of catarrhal or desquamative pneumonia may introduce the process. It 
is probable that in the majority of cases the terminal bronchioles, the 
alveolar passages, and the walls of the air cells afford the first resting 
place for the bacilli, and that in their immediate periphery the tuber- 
cular process is initiated. 

Outside of the pulmonary organs the pathological changes that are not 
directly dependent upon the tubercular process are merely those which 
are characteristic of general anaemia and marasmus. 

Diagnosis. The diagnosis of consumption is easy when tubercle 



172 PARASITIC AXD INFECTIVE DISEASES. 

bacilli can be discovered in the sputa. In all cases of suspected pul- 
monary disease careful search should be made for their existence. 
Sometimes, however, they are absent for a time, though tuberculosis 
may exist. Repeated examination will finally result in their discovery. 
In this way the nature of early haemoptysis may be frequently deter- 
mined, and the character of the catarrhal bronchitis involving the apex 
of the lungs may be explained. It must not be forgotten that bron- 
chitis in that locality does not always indicate the existence of pulmo- 
nary tuberculosis, since it may be excited by other causes. In the 
absence of bacillary sputa, the history of the case, the existence of 
scrofula in early life, and the physical signs must be considered in 
order to arrive at a conclusion. The existence of hectic fever and 
progressive emaciation without other assignable cause, are valuable in- 
dications of pulmonary consumption. When the physical signs of pul- 
monary infiltration are discovered, it becomes necessary to differentiate 
them from the similar signs that are observed in pneumonia. Tuber- 
cular infiltration usually commences in the apex of the lung, and when 
both lungs are thus infiltrated the probabilities are decidedly in favor 
of consumption. An acute and rapid course of the disease, followed 
by subsidence of fever and disappearance of physical signs, is indicative 
of pneumonia. 

Tubercular caverns can be differentiated from the cavities that are 
produced in pulmonary gangrene by the absence of the odor of putre- 
faction from the matter that is expectorated. The cavities that result 
from bronchiectasis are usually situated in the inferior and posterior 
portions of the lungs. The discharge from a pulmonary abscess con- 
tains fragments of lung tissue and crystals of hsematoidin. 

Prognosis. The prognosis in the majority of cases is exceedingly 
unfavorable. When the patient is in such circumstances of affluence 
that he can seek a favored climate and a healthy locality where a life of 
ease can be enjoyed, the disease may be hindered in its course, or even 
entirely cured ; but in the ordinary conditions of poverty and misery 
pulmonary consumption is almost invariably fatal. The disease is liable 
to assume a rapidly progressive character among young people. The 
dangers are also greatly aggravated by hereditary influences. Entrance 
upon the marriage state, and the occurrence of pregnancy are condi- 
tions that operate unfavorably upon the course of the disease. When 
the lungs are extensively consumed and undermined by cavernous 
abscesses very little hope of recovery can be entertained, and it need 
hardly be added that the intercurrence of other diseases adds greatly to 
the dangers of consumption. 

Treatment. Prophylactic measures against pulmonary consump- 
tion are more effectual than the treatment of the disease itself. Since 
its occurrence is largely dependent upon the conditions that accompany 
poverty, the greatest benefit may be anticipated from every improve- 
ment that can be effected in the habitations, workshops, and abiding- 
places of the laboring classes. When the children of weakly or phthisi- 
cal parents enter the world, they should become at once the objects of 
forethought and scientific nurture. Consumptive mothers should not 
nurse their offspring, and if a healthy wet-nurse cannot be provided the 



PULMONARY CONSUMPTION — PHTHISIS PULMONUM. 173 

infant should be fed with milk from a healthy cow. It is often better 
to use a mixture of milk that is furnished by many cows, since it has 
been shown that sufficient dilution of milk from a tubercular source 
renders it innocuous. Boiling the milk should not be neglected, since 
in that way the tubercle bacilli may be effectually destroyed. As chil- 
dren who have inherited a predisposition to consumption advance in 
years they should be warmly clad and should take abundant exercise 
in the open air ; should be accustomed to gymnastic exercises, and 
should not be unduly urged in their studies at school. Their diet 
should be wholesome and sufficient ; their hours of sleep unbroken and 
regular, and they should be trained to the use of cold sponge baths, with 
plenty of friction upon the skin. Any disorder of the respiratory 
organs should receive prompt attention, in order to prevent those con- 
ditions that favor the entrance of tubercle bacilli. Such precautions 
are especially needful in connection with the ordinary infective dis- 
eases of childhood. The marriage of phthisically disposed individuals 
is in all respects undesirable, since it favors the manifestation of tuber- 
culosis, if not already present, and is exceedingly liable to aggravate its 
course if that has been actually commenced. Especially unfortunate is 
the union of a healthy person with a consumptive partner, since the 
contagion may be sometimes communicated by one to the other. This 
is particularly liable to occur when habits of cleanliness are not scrupu- 
lously observed, and when sputa containing tubercle bacilli are per- 
mitted to dry and mingle with the atmosphere of the residence. For 
this reason the sputa of consumptive patients should always be received 
in a covered vessel that contains water, which should be carefully 
cleansed before the expectorated matter has an opportunity to become 
dry and pulverulent. If possible, the sputa should be disinfected with a 
5 per cent, solution of carbolic acid. Spitting upon the floor and into 
handkerchiefs should never be permitted. Since the saliva sometimes 
contains tubercle bacilli, kissing and caressing of a consumptive patient 
should be strictly forbidden. If these simple precautions be avoided, 
the danger of direct infection becomes very slight. 

It is especially desirable that the apartments in which consumptive 
persons dwell should be freely illuminated by the sun, since it has been 
shown that the bacilli rapidly lose their vitality in the rays of sunlight. 
Abundant ventilation and frequent disinfection of such apartments 
should also be practised. The influence of climate upon the course 
of consumption is unmistakable when the disease is thus opposed in 
its early stages. In the later period of its course the most favorable 
climatic influences accomplish very little. In order to secure the best 
results the climate must be dry, mild, bracing, and equable. The 
atmosphere of the locality should be free from dust, smoke, and other 
impurities that prevail upon the lower levels of the continent. For this 
reason the mountainous and wooded regions of the country are prefer- 
able to the districts along the seacoast or in the great interior valleys. 
The purity of the air over the ocean at a distance from land, renders a 
sea-voyage in the temperate and tropical zones exceedingly desirable 
for such patients as can endure the discomforts of a long voyage and 
removal from home. Residence upon small islands in the midst of the 



174 PARASITIC AND INFECTIVE DISEASES. 

ocean affords an admirable means of securing the advantages of sea-air : 
and, frequently, when such islands are mountainous, the concurrent 
advantages of elevation above the sea-level can be also enjoyed. For 
this reason the island groups along the western coast of Africa, and the 
Sandwich Islands, in the Pacific Ocean, afford an ideal refuge for con- 
sumptive patients. The Island of Nassau, among the Bahamas, is also 
an excellent place of resort, though its lack of mountainous elevation 
renders it inferior to the high islands of the Atlantic and of the Pacific. 
Within the limits of the American Continent, the territories of Arizona, 
New Mexico, and the States of Colorado and California afford the best 
opportunity for securing the advantages of dry, pure air ; but unfortu- 
nately the distance of these resorts from the centres of population, and 
the lack of sufficient accommodation, render them less accessible and 
desirable than they will be at some future period. The Adirondack 
Mountains in New York, and the mountain resorts among the Alleghe- 
nies in Pennsylvania, Maryland, Virginia, North Carolina, Kentucky, 
and Tennessee, are at present the most accessible and salutary places 
of residence that possess any considerable reputation. The climate of 
Florida and of the coast of the Gulf of Mexico is exceedingly agree- 
able during the winter months of the year, but it lacks the bracing 
quality that is needful for the invigoration and reconstitution of a 
debilitated invalid. The highlands of Mexico and of Southern Cali- 
fornia possess a well-deserved reputation, but even there, as elsewhere, 
there is a great opportunity for choice between different localities, so 
much depends upon local conditions by which are determined the rela- 
tive dryness and salubrity of any given situation. For this reason, the 
dry, cold, bracing winter weather of the northern lakes and of the 
States around the head waters of the Mississippi and Missouri rivers, is 
often to be preferred to the mild and relaxing atmosphere of southern 
latitudes. Only when a patient cannot endure the severity of a north- 
ern winter, and is thereby unable to obtain exercise in the open air 
during that season of the year, should he be advised to seek a residence 
near the Gulf of Mexico or upon the Pacific slope. But, under no cir- 
cumstances, should a patient who is far advanced in consumption, whose 
lungs are riddled with cavities, and who is liable to rapid exhaustion 
and sudden death, be advised to leave a comfortable home, in the vain 
hope of recovery in a distant and untried resort. Especially injurious 
is the rapid removal to an elevated residence several thousand feet 
above the sea-level, since under such circumstances an extensively infil- 
trated lung cannot easily adapt itself to the necessities of respiration in 
an attenuated atmosphere. Pulmonary hemorrhage is also to be feared 
under such conditions. Hemorrhagic cases should seek the level of the 
shore, rather than a mountainous elevation. 

The diet of the consumptive patient should receive the greatest atten- 
tion. During the early stages of the disease, before the formation of 
extensive cavities in the lungs, great benefit may be derived from the 
Weir Mitchell method of feeding, combined with rest and massage. In 
advanced cases of the disease the condition is virtually that of slow 
starvation, hence dietetic measures are of the greatest importance. The 
unconquerable disgust for food that sometimes exists may render com- 



PULMONARY CONSUMPTION — PHTHISIS PULMOXUM. 175 

pulsory feeding an absolute necessity. Milk, eggs, cocoa, chocolate, 
the tenderest meats, bread, butter, cream, wine, beer, extract of malt, 
rich broths, and well-made soups should be abundantly furnished. In 
many cases a luncheon should be supplied between the regular meals, 
and a glass of milk or of good beer should be taken on retiring at night. 
Cod-liver oil is of great value as a means of hindering the progress of 
emaciation. It should be given after meals in the largest dose that can 
be tolerated by the stomach, and some other vehicle rather than whiskey 
should be chosen, since alcohol increases the existing gastric catarrh. 
Sometimes it is necessary to commence with single-drop doses, which 
are to be gradually increased as the stomach becomes tolerant of 
the oil. 

For the relief of cough, narcotics and expectorants are necessary. 



. . — Morph. sulph. .... 


• gr. iij. 


Spt. chloroform. J 




Tr. cannab. ind. y aa 


• 3J- 


Acid, hydrocyan. dilut. J 




Tr. hyoscyam. .... 


• 3ij- 


Acid, phospli. dilut 


• ^iij- 


Syr. ipecac. \ a - 
Syr. scillse / 


• 3V- 


Glycerini ...... 


. ^ iijss.— M. 


■A teaspoonful every four hours. 





If it be desirable to omit syrup from the combination, an aqueous 
solution of apomorphine may be substituted for the syrups of ipecac and 
squills. 

J£. — Morph. sulph. . gr. j-ij. 

Acid, hydrocyan. dilut 3J- 

Syr. tolut z xv. 

Aquae *jj._M. 

S. — A teaspoonful every four hours. 

It is, however, desirable to avoid any considerable use of opiates, 
since they impair the appetite, and the length of the disease may render 
the use of large doses necessary before its conclusion. When the patient 
is annoyed by an excessive bronchial secretion, mineral waters that are 
rich in chloride of sodium may be employed wdth advantage. In such 
cases the wine of tar, tar-water, and terpin hydrate are useful. Oxalate 
of cerium is often beneficial in doses of five to ten grains every four 
hours. The advance of anaemia may be resisted by the administration 
of various preparations of iron. The arseniate of iron does good ser- 
vice in many cases. Three drops of Fowler's solution with a table- 
spoonful of compound iron mixture can be taken three times a day with 
considerable benefit. Carbonate of iron is another excellent prepara- 
tion, and the ferrated mineral waters are often very beneficial. Loss 
of appetite, especially when attended by qualms of nausea, can be often 
relieved by the administration of bitter tonics. 



R .— Strych. sulpl 



Quin. sulph. 
Acid, sulph. arom. 
Syr. cort. aurant. 
Aquae 
S. — A teaspoonful in a wineglass of water before each meal. 



gr- J- 
3ss. 

S3- 

a vi .i- 
I "J— M- 



176 PARASITIC AND INFECTIVE DISEASES. 

The compound tinctures of cinchona and of gentian are useful. For 
delicate patients the elixir of calisaya bark is a valuable aid. 

When hectic fever exists, its paroxysms may be considerably short- 
ened and reduced by the administration of phenacetine or acetanilide 
in five-grain doses every two hours, at the commencement of the attack. 
Antipyrine may be also employed if it does not cause nausea and depres- 
sion of the heart. Copious perspiration can be greatly diminished by 
the use of atropine. This may be administered in doses of yoir °f a 
grain at bedtime. A pill containing J of a grain of extract of bella- 
donna and two grains of oxide of zinc may be taken with benefit for 
the same purpose. Strychnine has also been administered successfully, 
and frequent sponge baths with moderately cold water containing alco- 
hol, serve to invigorate the system, and to reduce the tendency to per- 
spiration. A strong decoction of sage, drank cold at night, is not only 
soothing, but stimulating and antagonistic to perspiration. The treat- 
ment of haemoptysis will be considered in connection with diseases of 
the lungs. 

Many experimental methods of treatment have been recently intro- 
duced and as quickly abandoned. Among these may be mentioned the 
inhalation of hot air, compressed air, rarefied air, and medicated airs. 
Great hopes were at one time entertained of benefit from the injection 
of sulphuretted hydrogen into the rectum and intestines, but the effect 
of this medication was merely that of an anaesthetic, which, for a time, 
diminished the cough, but did not appreciably affect the progress of the 
disease. Innumerable other drugs have been prescribed with very 
indifferent success. In general, it may be said that everything which 
assists digestion, increases the growth of the blood, and invigorates the 
health, is of service in retarding the course of the disease, but beyond 
these indirect influences very little can be expected from ordinary medi- 
cation. 

Very recently, Koch, the discoverer of the tubercle bacillus, intro- 
duced a method of treatment by which it was hoped that the prolifera- 
tion of the specific bacilli in the tissues might be directly antagonized ; 
but after extensive trials, a feeling of general disappointment has suc- 
ceeded to the enthusiasm with which the experiment was first under- 
taken. The method consists in the injection, every other day, of a 
glycerin solution of the products of the tubercle bacillus, obtained by 
its culture in appropriate media. To the secretions thus gathered and 
dissolved has been given the name tuberculin. The amount of fluid 
that is injected should not exceed half a milligramme at first. This 
quantity may be gradually increased, but probably should never exceed 
one-fifth of a cubic centimetre. The liquid should be diluted with a 
one-half of one per cent, solution of carbolic acid. Every precaution 
should be taken for the thorough disinfection of the apparatus, and the 
injections may be made into the subcutaneous areolar tissue just below 
the shoulder-blade or in the lumbar region, since these parts are least 
sensitive to the operation. The injection is usually followed by high 
fever that lasts for several hours, if tuberculosis actually exists in the 
tissues of the patient. More recent experiments seem to indicate that 
it is not advisable to operate with doses sufficient to produce such 



LARYNGEAL TUBERCULOSIS. 177 

violent reaction. The treatment must be continued until it is no longer 
followed by any febrile movement. Usually many months are requi- 
site for its efficient use, and the ordinary hygienic methods are as 
necessary as they ever were before the introduction of the new method. 

Laryngeal Tuberculosis — Phthisis Laryngea. 

Etiology. Laryngeal tuberculosis includes all those ulcerative 
processes that occur in the larynx as a consequence of invasion by the 
tubercle bacillus. The disease occurs more frequently among men 
than among women, and is especially common between the ages of 
twenty and thirty years. It is usually associated with pulmonary con- 
sumption as a secondary consequence of the infection of the lungs. It 
is probably due to the migration of bacilli from the lungs into the tissues 
of the larynx. It is not impossible that a primary- infection of the larynx 
may take place through inspiration of dust containing tubercle bacilli. 

Pathological Anatomy. In the vast majority of cases the tuber- 
cular process commences in the sub-epithelial tissues of the larynx. 
Tubercular infiltrations are there formed, and there undergo caseation. 
The overlying epithelial surface becomes pale, thickened, softened, and 
finally necrotic. In this way tubercular ulcerations are formed which 
are variable in size, and which occasionally extend into the trachea, 
though more frequently into the tissues between the larynx and the 
base of the tongue. In certain cases the tubercular process commences 
in the follicles of the laryngeal mucous membrane. (Fig. 80.) 

The ulcerative process generally occupies the posterior wall of the 
larynx, and the mucous membrane upon 
the posterior extremities of the vocal FlG - 80 - 

cords. It also invades the arytenoid j^"~? ^iiJrJ^* 

cartilages and the epiglottis. By the 
coalescence of numerous small ulcers, a 
large portion of the organ may be eroded 
and rendered useless for vocal utterance. 
The cartilaginous structures of the larynx 
may become involved in the process, and 

n . i i ,• i i ^i Laryngeal phthisis, showing 

tatal oedema sometimes concludes the , , ,. , , ,. % 

. , . : . \ destruction of a large portion of 

Scene. A tendency to Cicatrization and the epiglottis and general ulcera- 

repair of the ulcerated tissues is scarcely tion. (Morbll Mackenzie.) 
ever observed. 

Symptoms. With the aid of the laryngoscope, the progress of 
laryngeal tuberculosis may be easily followed. The mucous membrane 
at first appears swelled, pale, and uneven. These appearances are 
followed by visible erosion and the ordinary evidences of ulceration. 
Sometimes a great disproportion may be remarked between the amount 
of local destruction of tissue and the modifications of the voice. In 
some cases the voice is lost, though very little ulceration be visible ; 
while in other cases the opposite conditions exist. Great importance 
undoubtedly must be ascribed to the effects of muscular weakness and 
mucous swelling. 

The majority of patients complain of great uneasiness and irritation 

12 



V( IM 






178 PAEASITIC AND INFECTIVE DISEASES. 

in the throat and in the parts between the pharynx and middle ear. A 
harassing cough, with muco-purulent and frequently offensive sputa, 
serves to torment the patient by day and by night. The act of swal- 
lowing is often intensely painful, and sometimes the lesions are of such 
a nature that liquids find their way from the pharynx into the larynx 
without the possibility of their exclusion. The symptoms of pulmonary 
consumption also complicate the case in the majority of patients, though 
occasionally the disease is confined to the larynx alone Cicatrization 
and recovery are exceedingly rare events Death generally occurs as a 
result of exhaustion, or of suffocation through the sudden development 
of oedema of the glottis. The prognosis is, of course, most unfavorable. 

Diagnosis. With the aid of the laryngoscope for inspection of the 
larynx, and of the microscope for the examination of the sputa, the 
diagnosis of laryngeal tuberculosis is quite easy. In order to avoid the 
error of referring tubercle bacilli from pulmonary sputa to a laryngeal 
source, it is advisable to procure for microscopical examination a portion 
of the muco-purulent discharge from the laryngeal ulcer by the intro- 
duction of a earners-hair pencil into the larynx. Guided by the mirror, 
a sufficient quantity of the secretion may be thus obtained for subse- 
quent examination. In this way a tubercular ulcer may be distinguished 
from syphilitic ulcerations within the larynx. Greater difficulty is pre- 
sented by cases in which there exists a combination of laryngeal syph- 
ilis with tuberculosis of the larynx and of the lungs. Hypodermic 
injection of tuberculin has been employed as a diagnostic aid, since, 
after the injection, the margins of a tubercular ulcer become greatly 
reddened and swelled ; but the operation is not without considerable 
danger in the way of exciting oedema of the glottis. 

Treatment. The treatment of laryngeal ulceration is largely sur- 
gical, and consists in curetting the ulcers, or in their thorough cauteri- 
zation with nitrate of silver, creasote, or lactic acid. Various insuffla- 
tions are recommended for the purpose of stimulating the ulcerated 
surfaces (iodoform, iodol, menthol, etc.). The hypodermic use of 
tuberculin in very minute doses has been followed by improvement in 
many cases, and sometimes by apparent recovery. 

"When it becomes necessary to fall back upon simple palliative treat- 
ment, pain may be relieved by frequent pencilling of the laryngeal 
cavity with a ten per cent, solution of cocaine. Inhalation of the pul- 
verized vapor of a one per cent, solution of bromide of potassium often 
gives great relief when there is an irritating cough. Simple inhalations 
of a one-half of one per cent, solution of carbolic acid, or of liquor 
aluminii acetici are excellent means of disinfection when the sputa and 
the breath are offensive. 

The occurrence of suffocation from oedema of the glottis, or from the 
development of great tumefaction within the laryngeal cavity, render 
necessary the operation for tracheotomy. 

Pharyngeal Tuberculosis — Phthisis Pharyngea. 

The etiology and pathological changes of pharyngeal tuberculosis do 
not differ in any essential particular from those which have been already 



INTESTINAL TUBERCULOSIS. 179 

described under the head of laryngeal tuberculosis. The cervical 
lymph glands exhibit a greater tendency to enlargement and induration, 
since they are intimately connected with the pharyngeal and faucial 
structures. 

Symptoms. The amount of pain and difficulty in swallowing varies 
greatly in different patients. It is frequently quite out of proportion 
with the extent and severity of the local lesions. The course of the 
disease is sometimes very rapid, with extensive diffusion of miliary 
tuberculosis throughout the body. In other cases the disease progresses 
slowly, with but little evidence of general excitement. The tongue, 
the larynx, the oesophagus, and the intestines are very liable to invasion 
as the disease advances. 

Diagnosis. The disease can be readily recognized by the presence 
of tubercle bacilli in the secretions from the ulcerated surfaces. Without 
this test it is sometimes quite difficult to distinguish the tubercular ulcer 
from a syphilitic sore. 

Treatment. The local treatment of the pharynx consists in the 
relief of pain by frequent pencilling of the ulcerated surfaces with a 
four per cent, solution of carbolic acid in glycerin, or a twenty per cent, 
solution of bromide of potassium in glycerin, or a ten per cent, solution 
of cocaine. The ulcers should be thoroughly cauterized with the 
galvano-cautery, or with its substitutes, nitrate of silver, chromic acid, 
or lactic acid. 

Intestinal Tuberculosis — Phthisis Enterica. 

Etiology. Intestinal tuberculosis is, among adults, almost invariably 
a secondary consequence of pulmonary consumption, the intestinal 
mucous membrane being invaded by the tubercular contents of the 
sputa that are swallowed by the patient. Among children who con- 
sume the milk of tubercular cows it may exist as a primary disease. 

Pathological Anatomy. The favorite seat of tubercular ulcera- 
tion in the intestinal wall is the lower portion of the ileum and the 
upper portion of the colon. The number of ulcers is exceedingly 
variable, being sometimes very numerous, and in other cases reduced to 
a single lesion. 

The ulcerative process commences in the follicles of the intestine. 
Both the solitary glands and the agminated may become centres of the 
process. The follicular elements proliferate, swell, undergo caseation, 
softening, and evacuation. These stages of the necrotic process are 
indicated at first by circumscribed swelling, and finally by the forma- 
tion of deep crater-like ulcers with sharply defined margins, constituting 
what are called primary intestinal ulcers. As these enlarge they may 
become confluent, so that in many cases extensive and irregular lesions 
of substance are visible. They tend to develop along the lymph vessels 
and bloodvessels which enter the intestine, and, consequently, present 
an oval form with the long axis parallel to the circumference of the 
intestine. Sometimes the gut is completely surrounded by a zone of 
ulceration that has been thus developed. Under the serous investment 
of the intestine, in the neighborhood of the intestinal ulcers, deposits 



180 PARASITIC AND INFECTIVE DISEASES. 

of miliary tubercle are frequently observed, and they may be traced to 
a considerable distance along the course of the lymphatics. Perforation 
of the intestinal wall rarely occurs, since the base of the ulcer is thick- 
ened by exudation that prevents its penetration into the peritoneal 
cavity. Cicatrization is not often witnessed, though occasionally the 
gut may be constricted by an old scar. The mesenteric glands usually 
become infected and greatly enlarged ; they frequently undergo caseous 
degeneration, sometimes suppurate, and may be often recognized as 
prominent tumors within the abdomen. 

Symptoms, Diagnosis, and Prognosis. Intestinal tuberculosis 
sometimes exists for a long time without conspicuous symptoms, until 
microscopical examination of the feces results in the discovery of charac- 
teristic tubercle bacilli. But sometimes the disease forcibly arrests 
attention by the sudden occurrence of most formidable symptoms, such 
as intestinal hemorrhage, evidences of general or circumscribed peri- 
tonitis, symptoms of perforation and collapse, which result from sudden 
rupture of a bloodvessel or of the intestinal wall. 

One of the most characteristic symptoms of intestinal tuberculosis is 
diarrhoea. This is excited by irritation of the intestinal wall, and by a 
catarrhal condition of the mucous membrane between the ulcerated sur- 
faces. The diarrhoea is especially troublesome during the latter part of 
the night and in the early morning. The feces are exceedingly offen- 
sive, watery, and charged with undigested food. Sometimes, when the 
ulcerative process is limited to the upper portion of the small intestine, 
the bowels may be quite constipated. Blood and pus sometimes appear 
in considerable quantity mixed with the feces, and they can be fre- 
quently recognized by the aid of the microscope when not visible to the 
naked eye. Occasionally fragments of the intestinal wall may be dis- 
covered. Pain is usually experienced in the abdomen. Sometimes it 
is absent, but in the majority of cases it occurs either spontaneously or 
as a result of pressure over the abdominal walls. The most frequent 
seat of tenderness is in the right iliac fossa, where ulceration is often 
observed. Vomiting is a rare event, unless peritonitis occurs. The 
appetite is usually destroyed, though sometimes it is quite voracious. 
As a patient becomes emaciated, enlarged mesenteric glands and indu- 
rated ulcers can be often felt through the abdominal wall. The prog- 
nosis is almost inevitably fatal. Death occurs either as a consequence 
of exhaustion, or through the development of various complications. 

Treatment. The general treatment that has been recommended 
for pulmonary consumption is useful in the intestinal form of the dis- 
ease. The diet should consist principally of milk, koumiss, eggs, broths, 
and animal food that yields little refuse for the formation of irritating 
feces. The occurrence of diarrhoea requires the use of opiates and 
other remedies, as recommended in the treatment of enteric inflamma- 
tion. Large doses of bismuth subnitrate or of bismuth salicylate may 
be administered with benefit. If the lower portion of the colon and 
the rectum are ulcerated, solutions of nitrate of silver (one to five parts* 
per thousand) may be employed in the form of an intestinal injection. 
The fluid should be conveyed through a long rectal tube above the 
sigmoid flexure of the colon. 



TUBERCULOSIS OF THE KIDNEYS. 181 

In cases that are complicated by constipation, it is desirable to irri- 
gate the colon with large quantities of warm water, for the purpose of 
removing fecal accumulations that might irritate the ulcerated surfaces. 
Gentle laxatives may also be administered with advantage. If pain 
afflicts the patient, hypodermic injections of morphine and warm poul- 
tices should be prescribed. 

Tuberculosis of the Kidneys and Urinary Organs — Phthisis 

Renalis. 

Etiology. Tuberculosis of the kidneys may occur as a primary 
disease, involving the kidneys alone, or extending from them into the 
neighboring urinary and sexual organs; or it may occur as a secondary 
consequence of pulmonary consumption, or of some other variety of 
tuberculosis. It is often difficult to decide whether the disease occurs 
as a primary or a secondary process; nor is it always possible when it 
is primary in its character to trace the avenue of infection by which 
the tubercle bacilli have entered the kidneys. Far more easy is the 
determination of the manner in which secondary infection of the renal 
organs takes place. When the lungs are the seat of primary tubercu- 
losis, the contagion is transported through the lymphatic canals and the 
bloodvessels. Sometimes the same channels serve to convey contagion 
from the genital organs to the kidneys. The occurrence of epididymitis 
through gonorrhoeal infection may favor the occurrence of subsequent 
tubercular infection of the affected organ. From this, tubercle bacilli 
can be easily transported to the kidneys, where they excite a secondary 
tubercular process. Similar infection may result from copulation with 
a tubercular person. The bacilli may be contained in the sperm, or in 
the vaginal fluids. 

Pathological Anatomy. The tubercular process sometimes in- 
volves the whole length of the urinary passages, but sometimes it 
occupies scattered and detached portions of those channels. In certain 
cases the process ascends from the epididymis through the bladder and 
ureters to the kidneys, while in other cases a descending course is 
observed. Ascending tuberculosis usually affects the kidneys upon the 
same side with the original focus of infection in the epididymis. When 
one kidney alone is involved, the other may be completely healthy, 
or it may exhibit a condition of chronic inflammation. 

In the kidneys, the tubercular process commences in the papillae and 
advances toward the cortex of the organ. The usual stages of infiltra- 
tion, caseation, softening, and evacuation are witnessed, so that the 
kidney, like the lungs, finally becomes riddled with suppurating cavi- 
ties. Through coalescence of these cavities the entire kidney may be 
finally disorganized, and nothing left but a pus-filled sac, formed by the 
thickened capsule of the kidney. The pelvis of the organ is usually 
dilated in consequence of the obstruction of the ureter and stagnation 
of urine. In many cases the ureters are themselves involved in the 
tubercular process, and as a consequence of the obstruction thus pro- 
duced they become greatly deformed and distended. The mucous 
membrane of the bladder, especially in the neighborhood of its neck, 



182 PARASITIC AND INFECTIVE DISEASES. 

very commonly undergoes extensive ulceration, and sometimes the 
ulcerated surfaces become incrusted with phosphatic salts. When the 
urethra is ulcerated, the peri-urethral tissues are frequently invaded 
and infiltrated. Not infrequently perforation of the urinary passages 
may occur as a consequence of tubercular ulceration. The ordinary 
consequences of peritoneal perforation are then manifested. 

Symptoms and Diagnosis. In many cases the symptoms are 
identical with those of catarrhal inflammation of the bladder, and only 
after the microscopical examination of the urinary sediment, and the 
discovery of tubercle bacilli, is the true nature of the disease rendered 
manifest. 

The urine is often considerably increased in quantity, but its specific 
gravity usually remains unchanged. The sediment often contains pus 
and minute caseous masses which are of great significance. When the 
disease has progressed to a considerable extent, numerous epithelial 
cells, round cells, and degenerated elements from all parts of the urinary 
apparatus may be discovered in the urine. Triple phosphates are 
usually present whenever there is stagnation of urine in the bladder, 
even though the reaction of the liquid still remains acid. The amount 
of albumin in the urine is proportionate with the quantity of pus, unless 
the kidneys are also in a state of inflammation. Under such circum- 
stances the amount of albumin follows the usual rule. Ulceration of 
the bladder is accompanied by decomposition of the urine, which 
becomes ammoniacal and exceedingly offensive. Sometimes the urethra 
is obstructed by fragments of detritus, and there is always great 
uneasiness and pain in the act of micturition. 

When the kidneys are involved in the tubercular process, pain is 
usually experienced in the region of the organs. Sometimes the suf- 
fering is very great, and distress is felt not only in the loins but through 
the abdomen, in the groins, testicles, and thighs. The pain is some- 
times continuous, sometimes intermittent, and in certain cases entirely 
absent, though it can be generally excited by pressure below the ribs. 
The enlargement of the kidney sometimes varies in size, and its dimi- 
nution is frequently accompanied by a copious discharge of urine, 
indicating a temporary obstruction of the ureter that had finally given 
way. Such obstruction is sometimes attended by chilliness and fever, 
consequent upon retention of pus in the pelvis of the kidney. Such 
purulent accumulations sometimes lead to rupture and external dis- 
charge of pus, and under such circumstances the symptoms of abscess 
and fistula are associated with those of tuberculosis. 

Uro-genital tuberculosis is often associated with tuberculosis in other 
organs. The patient becomes anaemic, and finally dies of exhaustion 
or from obstinate diarrhoea, miliary tuberculosis, or secondary inflam- 
mation of the kidneys. 

Prognosis and Treatment. The prospect of recovery is exceed- 
ingly small. In very rare instances apparent recovery has been known 
to occur in cases of primary tuberculosis. Treatment avails little more 
than to afford partial relief from pain, and to meet the local symptoms 
as they arise. Irrigation and disinfection of the bladder serve to 
diminish the amount of suffering that is consequent upon inflammation 



MILIARY TUBERCULOSIS. 183 

and ulceration of that organ. The general treatment of tuberculosis 
should be employed ; and when abscesses develop in any portion of the 
uro-genital tract that is accessible, surgical measures become necessary. 
When a single kidney alone is involved, it may be removed if enlarged 
and painful. Incision of the bladder has also been performed for the 
relief of severe and obstinate ulceration; the cavity of the organ is 
then to be treated by drainage and disinfection, like any other extensive 
abscess. 

Miliary Tuberculosis — Tuberculosis Miliaris Disseminata. 

Etiology. Generally, miliary tuberculosis consists in the wide dif- 
fusion of minute, gray tubercular nodules, of which the growth is 
excited by the tubercle bacillus. The disease is usually a secondary 
consequence of tubercular infiltration in the lungs or other portion of 
the body. From this central point of departure, minute portions con- 
taining the infective virus are transported through the vascular and 
lymph channels of the body until they find lodgment at a distance from 
the point of departure. In this way the dissemination of miliary 
tuberculosis resembles the ordinary embolic process by which the 
arterial circulation is obstructed when vegetations break loose from the 
valves of the heart. 

The infective focus may be located in any organ or tissue of the 
body. It is sometimes found in an incision or wound that has been 
infected from without. It has been observed that when caseous masses 
in the lungs are surrounded by a firm capsule of connective tissue, 
miliary tuberculosis seldom occurs. The process is excited by exposure 
to cold, and by other disturbing causes that unfavorably influence the 
health. Operations upon tubercular bones, the rapid absorption of 
serous effusions after tubercular pleurisy, and active treatment with 
injections of tuberculin, are sometimes followed by the wide dissemina- 
tion of tubercular virus and the occurrence of miliary tuberculosis. 

Pathological Anatomy. Miliary tuberculosis occurs more fre- 
quently in the liver than in any other organ. The lungs stand next in 
order, and after them the kidneys, intestines, and spleen. In the other 
organs of the body it less frequently occurs. In the stomach, salivary 
glands, and pancreas, it is scarcely ever observed. In the lungs the 
tubercular masses exist in the form of minute nodules which may be 
felt scattered in every portion of the organ, often feeling like small shot 
in the substance of the lung. The pleural membranes are frequently 
involved at the same time. Similar deposits are frequently found in the 
substance of the heart, in the pericardium, and upon the endocardial 
membrane. The walls of the veins frequently exhibit tubercular de- 
posits, and they are sometimes visible in the arterial coats. 

The spleen frequently contains numerous miliary tubercles which 
often closely resemble the Malpighian bodies, but they can be readily 
distinguished by the absence of any connection with the bloodvessels, 
and by the presence of tubercle bacilli that can be easily discovered 
with the aid of the microscope. In the kidneys, miliary tubercles are 
chiefly located in the cortical portion. They can be sometimes traced 



184 PARASITIC AXD INFECTIVE DISEASES. 

along the course of particular arterial branches. The peritoneum is 
very often studded with miliary tubercles, producing thickening, adhe- 
sion, and contraction of the omentum and peritoneal surfaces. Perito- 
nitis or ascites generally exists in connection with the tubercular 
deposit. In the liver miliary tubercles appear in the interlobular con- 
nective tissue and within the lobules themselves. The meninges of the 
brain are very commonly invaded by miliary tuberculosis, producing 
the symptoms of tubercular meningitis. 

Symptoms. The symptoms of miliary tuberculosis are dependent 
in part upon general infection of the entire organism, and in part upon 
local lesions in the individual tissues and organs. The disease is gen- 
erally accompanied by fever which is variable in its type, being some- 
times continuous, sometimes remittent, and sometimes intermittent. In 
certain cases the period of exacerbation occurs in the morning rather 
than in the evening. The pulse is usually quite frequent, often reach- 
ing 120 or 130 beats per minute. Copious perspiration, eruptions of 
herpes around the mouth, and roseola over the anterior surface of the 
body, are frequently observed. Albuminuria and peptonuria are not 
uncommon. The intellectual functions are frequently disturbed, so 
that the patient either lies apathetic, delirious, or soporose. Sometimes 
maniacal excitement is manifested. Two particular types of the dis- 
ease are recognized, in one of which the symptoms closely resemble 
those of typhoid fever, while in the other the febrile movement exhibits 
a well-marked intermittent character. In doubtful cases the diagnosis 
can be sometimes established by microscopical examination of the blood, 
since it has been shown that in miliary tuberculosis the bacilli are con- 
tained in the blood, especially in that of the spleen. By puncture of 
the spleen, and withdrawal of a small quantity of blood with the aid of 
a hypodermic syringe, the presence of tubercle bacilli may be demon- 
strated. 

The local symptoms vary, according to the principal seat of the tuber- 
cular process. When the lungs are involved, the principal symptom 
often consists of an obstinate cough that torments the patient and can- 
not be relieved by narcotics. It is usually attended by pain in the 
thoracic and abdominal muscles, which become sore through excessive 
exercise in the act of coughing. If the bronchial passages are 
inflamed, the ordinary symptoms of bronchitis are added. The sputa 
sometimes contain streaks of blood, or may be of a dark-brown color, 
recalling the appearance of pneumonic sputa. Sometimes excessive 
dyspnoea is experienced, and the respiration is greatly hindered with- 
out any apparent cause for the disturbance. When such attacks 
assume a paroxysmal character, they present a considerable likeness to 
the paroxysms of asthma. Sometimes the attack is accompanied by 
considerable cyanosis, which may reach a high grade of intensity with- 
out any apparent cause for the discoloration of the surface. 

Sometimes a tympanitic resonance is elicited by percussion below the 
clavicles. This indicates excessive dilatation and tension of the air 
cells. Under such circumstances the *• cracked-pot sound" is some- 
times audible. The sputa do not contain tubercle bacilli unless the 



MILIARY TUBERCULOSIS. 185 

miliary process is complicated with ordinary caseous infiltration of the 
Jungs. 

Miliary tuberculosis of the pleural membranes frequently involves 
one or both sides of the thorax, and its symptoms are masked by the 
symptoms of ordinary pleurisy with exudation. In like manner, 
miliary tuberculosis of the other serous membranes of the body may 
be overlooked, or considered merely symptomatic of ordinary serous 
inflammation. 

Miliary tuberculosis of the kidneys is less than a chronic tubercular 
infiltration likely to cause the appearance of albumin in the urine ; so, 
also, the appearance of tubercle bacilli in the feces is indicative of chronic 
tuberculosis rather than of the miliary process. 

When miliary tuberculosis is widely diffused, the choroid membrane 
of the eye is sometimes invaded by gray granulations which can be 
readily detected with the ophthalmoscope. 

The course of miliary tuberculosis is usually very rapid, and speedily 
reaches a fatal termination. The average duration of the disease is 
from four to eight weeks, though in certain cases it may be protracted 
for many months. Death rarely occurs before the end of the second 
week, and is due sometimes to collapse, or to the development of an 
excessively high temperature, or dyspnoea, meningitis, dissolution of 
the blood, and universal hemorrhage, or to other complications involv- 
ing the vital organs of the body. 

Diagnosis. When tubercle bacilli can be discovered in the blood, 
or when miliary tubercles are visible within the eye, the diagnosis is 
very certain ; but under other circumstances it is frequently attended 
with considerable doubt and difficulty. The existence of chronic tuber- 
culosis in any portion of the body favors the diagnosis of miliary 
tuberculosis. When acute symptoms supervene in the catarrhal form 
of the disease, it differs chiefly from acute bronchitis in the greater 
degree of general prostration that accompanies its course. From 
pneumonia the disease differs in the absence of well-marked consolida- 
tion of the lungs, and of the characteristic course of pneumonic inflam- 
mation. Rusty sputa are sometimes present in both diseases. Inter- 
mittent fever exhibits a more clearly defined paroxysm, and yields 
readily to quinine. From typhoid fever the disease differs positively in 
the character of the infective bacilli. When these can be demonstrated, 
the diagnosis is certain. It may be also remarked that the course of 
miliary tuberculosis presents less uniformity than that of typhoid fever. 
The abdominal distention, diarrhoea, and eruption of typhoid fever are 
also absent, and bronchitis is usually less conspicuous a symptom in 
typhoid fever than in miliary tuberculosis. The association of renal 
inflammation with miliary tuberculosis may render very difficult the 
diagnosis between the symptoms of the miliary process and those of 
uraemia. When miliary cancer invades the lungs, the diagnosis will be 
aided by the discovery of a primary cancerous tumor, and by a knowl- 
edge of the fact that carcinoma and miliary tuberculosis are very rarely 
associated. Occasionally the stupor and cyanosis that accompany 
miliary tuberculosis closely resemble the similar symptoms that attend 
poisoning with narcotics. When the course of the disease is unattended 



186 PARASITIC AND INFECTIVE DISEASES. 

by fever, and is characterized by maniacal excitement, the symptoms 
might be very easily mistaken for those of acute mania. 

PROGNOSIS and Treatment. The prognosis is always unfavorable, 
though temporary recovery is sometimes observed. Usually, however, 
in such cases the symptoms are renewed whenever a fresh diffusion of 
the tubercular virus takes place. The treatment is largely symptom- 
atic, since we possess no means of successfully opposing the course of 
the disease. Ordinary anti-febrile remedies may be employed for the 
relief of fever, and narcotics are prescribed to allay pain or to procure 
sleep. Hypodermic injections of tuberculin seem to be of little value, 
if they be not actually injurious, since the process of miliary tuber- 
culosis has in certain cases appeared to be excited by this mode of 
treatment. 

Tubercular Meningitis — Meningitis Tuberculosa. 

Etiology. Tubercular meningitis is the result of a deposit of 
miliary tubercles in the meninges of the brain. During the process of 
infiltration the symptoms are negative. Only when an inflammation is 
excited by the tubercular process are acute symptoms apparent. 

The primary source from which the contagion is derived may exist 
in caseous lymph glands, in caseous masses deposited in different organs 
of the body, or in tubercular diseases of the skin, such as lupus. 

The disease occurs more commonly among males than among females. 
It is usually witnessed in children between the second and sixth years 
of life. It is rarely observed after the age of puberty. Its occurrence 
is more frequent during the cold months of the year than during the 
warm weather of summer. 

Pathological Anatomy. The vascular canals of the cranium, 
meninges, and brain are distended with blood. Sometimes miliary 
tubercles are visible along the course of the middle meningeal artery, 
or in the dura mater. The arachnoid surface of the dura mater fre- 
quently appears dry, and often exhibits minute points of hemorrhage. 
The pia mater also appears dry and tarnished. Minute tubercular 
granulations can be often discovered along the course of its vessels, and 
sometimes the larger vessels are accompanied by a delicate fringe of 
purulent exudation. 

The principal seat of exudation is located at the base of the brain, 
between the chiasm, the crura of the cerebrum, and the pons. The 
course of the Sylvian artery is another favorite seat of tubercular erup- 
tion and inflammatory exudation. The exudate is of a jelly-like con- 
sistency, and rarely exhibits any considerable serous effusion. It 
consists chiefly of round cells, pus corpuscles, and coagulable con- 
stituents. The tubercular masses are often found in a condition of 
degeneration and caseation. The convexity of the brain exhibits the 
effects of pressure ; its convolutions are flattened ; the sulci are more or 
less obliterated. The ventricular cavities are frequently distended with 
fluid of a serous character, sometimes containing flocculi of lymph, but 
rarely any pus corpuscles. The ventricular surfaces are usually soft- 
ened, and occasionally exhibit tubercular deposits. Sometimes a puru- 



TUBERCULAR MENINGITIS. 187 

lent tubercular inflammation exists in the choroid plexus. The surface 
of the cerebellum is also frequently invaded by a tubercular and inflam- 
matory process. The disease is not confined to the brain, but frequently 
invades the spinal cord and its membranes. In certain cases the tuber- 
cular eruption is circumscribed within narrow limits, and it is then 
more likely to invade the left side of the brain than the right. 

Symptoms. During the period of tubercular deposit no decisive 
symptoms are manifested. The patient may exhibit loss of appetite, 
pallor, debility, and depression of spirits. Only when inflammatory 
conditions exist, or when local compression of certain cerebral nerves 
results from infiltration or exudation, is attention attracted to the cere- 
bral disease. The course of inflammation is usually characterized by 
symptoms that are identical with those which attend the evolution of 
ordinary serous or purulent meningitis ; but the duration of the disease 
is often much more protracted in tuberculosis than in cases of ordinary 
inflammation, consequently the symptoms of tubercular meningitis suc- 
ceed one another more gradually than in the non-tubercular forms of 
inflammation. Tubercular meningitis is also sometimes characterized 
by remissions, during which an apparent recovery takes place ; only, 
however, to be followed at a later date by a renewal of the symptoms. 

The prodromic period of the disease is correspondent with the process 
of tubercular deposit. During this period there is evident disorder of 
the health. The little patient becomes fretful, irritable, and enfeebled. 
Sleep is restless, interrupted by dreams, and characterized in many 
cases by unconscious grinding of the teeth. The bowels become irreg- 
ular or constipated, and finally some one or more of the cranial nerves 
exhibit evidences of weakness or paralysis. In many cases there is 
ptosis or strabismus. These ocular symptoms, or the appearance of cho- 
roidal tubercles, are often the first decisive evidences of the disease. 
Now follow the special symptoms — headache, dizziness, stiffness of the 
neck, retraction of the head, sinking of the abdominal wall, obstinate 
constipation, fever of an irregular and hectic type, often accompanied 
by a transient flush upon one or both cheeks, vomiting, contracted 
pupils, intolerance to light, and, in many cases, a sharp and pitiful 
outcry that has been termed the hydro cephalic cry. The pulse is vari- 
able, and rapidly rises as the disease advances until it can be scarcely 
counted. The respiratory movement is irregular, frequent, and sigh- 
ing ; and, toward the close of the disease, it exhibits the Cheyne-Stokes 
form of respiration. (Fig. 81.) Sometimes there is no elevation of tem- 
perature, but in other cases it fluctuates considerably, or does not rise 
until the close of the disease. In certain instances the temperature is 
subnormal. As the disease progresses, the pupils become dilated, 
delirium is merged in sopor, and the patient becomes comatose. Death 
usually occurs during the second week of the disease ; sometimes, how- 
ever, the case lingers for a number of weeks. Great emaciation and 
exhaustion are developed, and the patient dies in a state of complete 
inanition and marasmus. 

Sometimes the acute symptoms of the disease are ushered in by convul- 
sions which may or may not be repeated during the subsequent stages 
of the malady. Sometimes conjugated deviation of the eyeballs, or 



188 



PARASITIC AXD INFECTIVE DISEASES. 



other compulsory attitudes, are exhibited by the patient. The child 
lies with the head burrowing into the pillow, or remains persistently 



RJ 



3. 
1 



Fig. 81. 






m 






1 



Cheyne-Stokes respiration. 1. Ascending series 
apnoea,witkone abortn'e 



ica. «. Descending series. 3. Period of 
spiration. 4. Period of apncea disturbed by urging tbe patient 
to make voluntary respirations. (Finlaysox.) 

fixed upon one side, with the arms and legs drawn up against the body. 
Sometimes during the period of unconsciousness an arm or a leg is kept 



TUBERCULAR PLEURISY. 189 

in constant rhythmical motion. In many cases the vasomotor nerves of 
the skin are easily paralyzed so that by drawing the finger-nail across 
the forehead or other portion of the surface, a persistent red mark may 
be produced. This, however, is not a diagnostic symptom, since it is 
sometimes observed in other diseases. Herpetic eruptions are common 
about the lips, and miliary eruptions are frequent upon other portions 
of the skin. In addition to the appearance of miliary tubercles upon 
the choroid, the iris is occasionally invaded. In such cases its color 
changes and appears clouded. The liver and spleen are sometimes 
enlarged, and albumin is frequently present in the urine. 

Diagnosis. Tubercular meningitis presents many points of resem- 
blance with ordinary serous, or cerebrospinal meningitis. It conse- 
quently becomes important to investigate the antecedents of the patient 
with reference to the occurrence of tuberculosis among the ancestors 
or other members of the family. The existence of previous tubercular 
disease in the individual himself should also be made an object of careful 
investigation. Non-tubercular forms of meningitis are usually more 
abrupt in their invasion, and more rapid in their course than the tuber- 
cular variety of the disease. The points of difference between tubercular 
meningitis and typhoid fever have already been indicated in the section 
on general miliary tuberculosis. When tubercular meningitis commences 
with a sudden development of paralysis without fever, the existence of 
embolism or thrombosis might be suspected. In such cases ophthalmo- 
scopic examination of the eyes, and microscopical investigation of the 
blood may afford valuable indications. Stiffness of the neck, with re- 
traction of the head, points toward meningeal tuberculosis. 

Prognosis and Treatment. The disease is almost inevitably fatal. 
The treatment must be largely symptomatic. Iodide of potassium and 
other similar remedies are generally administered, but without useful 
results. The bromides may be given when convulsions occur for the 
purpose of diminishing the tendency to local or general spasm that is 
often witnessed. Chloral hydrate may be administered for the purpose 
of favoring the occurrence of sleep when the patient is restless and 
sleepless. Other symptoms must be encountered as they appear. When 
cold applications are made to the head, care should be exercised that 
the pillow be not wet, and that damp cloths be not left long in contact 
with the scalp, since in this way a cold application speedily becomes a 
warm poultice. Ice-caps or irrigating coils are preferable when they 
are tolerated by the patient, but in many cases only cold sponging will 
be permitted by an irritable child. 

Tubercular Pleurisy — Pleuritis Tuberculosa. 

Etiology.— When tubercular infiltration occupies a superficial por- 
tion of the lungs, pleuritic inflammation frequently arises as a conse- 
quence of local irritation occasioned by the neighboring caseous mass ; 
but in many instances the pleural membrane is itself the seat of a tuber- 
cular deposit which may be either primary or the secondary consequence 
of local infiltration elsewhere. In this way pleuritic inflammation may 
frequently arise. It is not impossible that the products of exudation 



190 PARASITIC AND INFECTIVE DISEASES. 

in an originally simple inflammation of the pleura may become subse- 
quently infected by a tubercular invasion, and that in this way the 
phenomena of tubercular pleurisy may be originated. 

Pathological Anatomy. The deposit generally occurs in the form 
of miliary tubercles, though sometimes larger masses exist. The exu- 
dation that accompanies the tubercular process is usually of a serous 
character. It is sometimes tinged with blood, and occasionally becomes 
purulent. 

Symptoms. The mere presence of miliary tubercles in the pleural 
membrane occasions no marked or characteristic symptoms. When 
inflammation and exudation exist, the ordinary symptoms of pleuritic 
inflammation and exudation are present. 

Diagnosis. There are no characteristic symptoms by which the 
differential diagnosis can be established between tubercular and non- 
tubercular forms of pleurisy. The existence of pleurisy in a tubercular 
patient affords strong presumptive evidence in favor of tuberculosis as 
the underlying cause of the disease. The existence of double pleurisy 
is strongly suggestive of tuberculosis ; so also is the occurrence of a 
hemorrhagic effusion when the other causes of hemorrhage into the 
pleural cavity (cancer, scurvy, and Bright's disease) can be excluded. 
Tubercular bacilli seldom exist in the exudation, since they can be 
liberated only by ulceration of the infiltrated tissue. 

Prognosis and Treatment. The prognosis is exceedingly unfavor- 
able. The treatment of the disease should be conducted in accordance 
with the rules that are laid down for the management of ordinary cases 
of pleurisy. Puncture of the thorax seldom affords any favorable results, 
since the cause of the disease remains after evacuation of the pleural 
cavity. The operation should not be performed unless rendered 
necessary for the relief of the heart or other important organs. 

Tubercular Pericarditis — Pericarditis Tuberculosa. 

Etiology. Primary tuberculosis of the pericardium is a very rare 
event. When a tubercular deposit invades the pericardium, it is usually 
a secondary consequence of tuberculosis in other organs of the body. 
Sometimes a previous non-tubercular pericardial effusion may become 
infected and invaded by the tubercular process. 

Pathological Anatomy. When pericardial tuberculosis occurs in 
connection with general miliary tuberculosis, the deposit appears in 
the form of minute gray granulations, chiefly upon the epicardium and 
in the neighborhood of the large vessels. When the deposit is very 
abundant, the miliary tubercles frequently coalesce and form consider- 
able masses which become caseous, and sometimes undergo softening 
and ulceration. The exudation into the pericardial cavity is usually 
serous, but it may become hemorrhagic or even purulent. When 
ulceration occurs, copious hemorrhage sometimes follows, and death is 
thus occasionally produced. 

Symptoms and Diagnosis. It is impossible before death to be 
certain regarding the existence of a tubercular pericarditis, even though 
all the symptoms of pericarditis are presented in the person of a tuber- 



TUBERCULAR PERITONITIS. 191 

-cular patient. So far as the physical signs and symptoms are con- 
cerned, the two forms of pericarditis cannot be distinguished from one 
-another until death gives an opportunity for examination of the 
pericardial membrane. 

Prognosis and Treatment. The prognosis is exceedingly un- 
favorable. For the general rules of treatment see page 172. 

Tubercular Peritonitis — Peritonitis Tuberculosa. 

Etiology. Primary tuberculosis of the peritoneum very rarely 
•occurs. Local peritonitis is frequently excited behind a tubercular 
ulcer of the intestines or about the periphery of the tubercular lymph 
glands. In many cases tubercular peritonitis exists as a local mani- 
festation of general miliary tuberculosis. 

Pathological Anatomy. The peritoneum is usually studded with 
minute miliary tubercles, especially in the portion that forms the omen- 
tum. The folds of the intestines are usually adherent to one another. 
Adjacent organs, like the liver, the stomach, and the spleen, become 
connected by adhesive bands, and the entire cavity of the abdomen 
appears as if filled with a coagulable exudation that has penetrated 
every interstice and vacant space between the abdominal viscera. 
Sometimes there is considerable serous effusion, which may be tinged 
with blood or mixed with pus. In certain cases the effusion resembles 
the transudation of ascites. When the disease runs a chronic course 
the adhesions contract, and thus produce considerable displacement and 
constriction of the abdominal viscera 

Symptoms and Diagnosis. The existence of tubercular peritonitis 
may be inferred when the symptoms of local or general peritonitis 
occur in a tubercular patient, or when the symptoms of general tuber- 
culosis are exhibited. The sufferer complains of pain and distention in 
the abdominal region, and the symptoms of universal disorder of health 
and of progressive debility are rapidly developed. The functions of 
the stomach and of the intestinal canal are extensively deranged, pro- 
ducing indigestion, constipation, or diarrhoea. Febrile symptoms 
manifest great variety, sometimes exhibiting the characteristics of per- 
sistent hectic fever ; but in other cases the insidious advance of the 
disease is unattended by feverish disturbance. When there is con- 
siderable effusion into the peritoneal cavity, the symptoms of serous 
peritonitis are prominent, or the appearances of cirrhosis and ascites 
are closely counterfeited ; but when the inflammation is of an adhesive 
character, producing contraction and induration of the infiltrated 
membranes, the abdominal cavity appears to be occupied by numerous 
irregular, indurated masses which consist of thickened intestinal 
convolutions or portions of the contracted omentum. 

Prognosis and Treatment. The prognosis is very unfavorable, 
though recovery has been occasionally witnessed. The treatment must 
depend largely upon the character of the symptoms. Simple medical 
therapeutics rarely accomplish any conspicuous result, but it is claimed 
that the disease may be cured in about one-quarter of the cases by 
laying open the abdominal cavity, and thoroughly cleansing its contents 
by irrigation and drainage. 



192 PARASITIC AND INFECTIVE DISEASES. 



CHAPTER XII. 

GLANDERS— FARCY. MALLEUS HUMIDUS. 

Etiology. Glanders is an acute infective disease peculiar to the 
horse, ass, and mule, but communicable to the goat, sheep, rabbit, 
guinea-pig, and human beings. Dogs rarely contract the disease, and 
its inoculation upon them produces only local lesions. The course of 
the disease in the lower animals is not uniformly the same. Certain 
lesions are more conspicuous in one animal than in another. The- 
severity of the disease varies exceedingly, but every part of the body is 
liable to its invasion. Upon the skin it produces numerous tumors of 
variable magnitude — the so-called farcy buds or tumors ; in the con- 
nective tissues its ravages are characterized by multiple abscesses and 
by an inflammation of the lymphatic vessels which may extend to the 
lymphatic glands. In the respiratory passages the mucous membranes 
of the nose, pharynx, and trachea ulcerate and are destroyed. Pus- 
may collect in the sinuses of the head. Nodular deposits, lobular 
pneumonia, and abscesses may occur in the lungs, liver, and spleen : 
the testicles and the epididymis also may be inflamed and occupied by 
purulent accumulations ; the cavities of the joints may, in like manner, 
fill with pus. 

From animals thus diseased the virulent contagion may be conveyed 
in the muco-purulent matter that is discharged from the nasal passages, 
or in the pus that escapes from various ulcers and abscesses that exist 
in different parts of the body. This virus may be communicated 
directly from the diseased animal to man, or it may be conveyed by 
articles upon which it has been discharged. It may thus cling to 
clothing, harness, bridles, and utensils that have been employed in the 
neighborhood of the diseased animal. In some cases, however, it is 
impossible to trace the source of infection, so that it was formerly con- 
jectured that the disease might sometimes arise spontaneously. In the 
majority of instances it occurs among those who have been occupied in 
stables and among horses. The active agent of the contagion is a 
bacillus, almost as minute as the tubercle bacillus, which is colored by 
an aqueous solution of methylene-blue. Unlike the tubercle bacillus, 
it is not colored by Ehrlich's method, and it is bleached by nitric 
acid. 

The virus usually enters the human body through a scratch or other 
solution of continuity in the skin. It is said to have been communi- 
cated through the alimentary canal by eating the flesh of glandered 
horses, but this is very doubtful. It is also possible that infection may 
take place through the respiratory passages by inhaling virulent parti- 
cles with the air ; but it is probable that in such cases the patient is 
really inoculated through some insignificant lesion in the nasal or 
pharyngeal mucous membrane. Babes has succeeded in conferring the 



GLANDERS — FARCY. 193 

disease upon guinea-pigs by rubbing the skin of the animal with a 
virulent culture of the bacillus mixed with lanolin. 

Symptoms. The period of incubation generally does not exceed 
three to five days, though it is sometimes prolonged for a month, or 
even for a longer period of time. The mode of development is exceed- 
ingly variable, and the duration of the disease is equally variable. The 
acute form may lead to death in the course of a few days, while the 
chronic variety may persist for several years. When the disease mani- 
fests itself principally in the air passages of the body, it is called 
glanders ; when the principal seat of morbid action is in the lymphatic 
system, producing inflammation and multiple abscesses accompanied by 
a Cutaneous eruption, the disease is called farcy. Four principal 
varieties result from this classification : 

1. Acute Farcy. When the contagion has been introduced through 
a wound or puncture, the symptoms resemble those that follow a dis- 
secting wound. There is pain and swelling along the lymphatic vessels 
that communicate with the point of inoculation. The lymphatic vessels 
and glands become inflamed, the affected limb swells as if it were the 
seat of phlegmonous erysipelas. Subcutaneous abscesses form in the 
connective tissue ; the general symptoms of purulent infection are 
manifested ; there is headache, nausea, vomiting, pain in the back and 
limbs, and an irregular fever. The original seat of inoculation may 
heal during the course of the general symptoms, or it may become 
ulcerated. The ulcer is liable to assume the characteristics of 
phagedena. 

In many cases where the fact of inoculation has escaped observa- 
tion, the disease commences with general symptoms like those that 
characterize the other infective fevers, and it is only after six or seven 
days that the development of multiple abscesses in the subcutaneous 
tissue throws light upon the nature of the disease. These abscesses 
may form very rapidly without much disturbance of the adjacent 
tissues, or they may be characterized by great disturbance and by exten- 
sion of the inflammatory process to the lymphatic vessels and glands. 

After two or three weeks the characteristic eruption appears upon 
the skin. It is of the pustular form, and is accompanied by copious 
perspiration, and sometimes by the appearance of hemorrhagic patches 
upon the surface of the body. The eruption is attended with great 
prostration, and is followed in the course of a few days by delirium, 
stupor, muscular spasms, profuse perspiration, involuntary discharge of 
feces, and death. 

2. Chronic Farcy. This variety of the disease may be produced by 
inoculation or by general infection. The symptoms are less severe than 
in the acute variety, and are prolonged during a much greater period. 
After a month or six weeks, during which the patient suffers with 
inflammation of the lymphatics, with pains in the joints, and with vague 
general symptoms, abscesses begin to form. They are of considerable 
size, and follow one another by successive development. They gener- 
ally occur upon the limbs, near the joints, or in the muscles, where 
some contusion or other local injury has produced a predisposition to 
purulent inflammation. They may be large and diffuse, or they may 

13 



194 PARASITIC AXD INFECTIVE DISEASES. 

be indolent and circumscribed. They may ulcerate and evacuate their 
contents speedily, or they may remain unopened for months together. 
Their contents consist of blood and sanious pus. 

Abscesses that have evacuated themselves, or have been opened by 
the knife, are extremely liable to degenerate into chronic ulcers or 
fistulous openings that persist for a great length of time. The joints 
are painful, but do not often become the seat of purulent inflammation. 
The skin is rough and dry, but does not exhibit any eruption. The 
general health is disturbed, the patient falls into a condition of cachexia, 
which may terminate either in acute glanders, or may occasionally re- 
cover after a duration of many months or years. 

3. Acute Glanders. This variety of the disease may exist as the 
terminal stage of the chronic forms of the disease, or it may occur as 
an independent result of inoculation. The first stage of the disease is 
characterized by the local phenomena that follow inoculation, or by the 
general symptoms of infection. These phenomena are followed by the 
development of abscesses, sometimes accompanied by the appearance of 
erysipelas upon the face, and occasionally upon the limbs. About the 
same time, or more frequently after the appearance of erysipelas, 
toward the end of the first week of the disease, an eruption of pustules, 
like those of ecthyma or of smallpox, appear all over the body and 
limbs. Their number may vary from a single pustule to many hun- 
dreds. They are generally discrete, but sometimes become actually 
confluent. They are sometimes very small, and occasionally constitute 
bullae nearly an inch in diameter filled with sanious pus. The ten- 
dency to gangrene manifests itself in the parts that have been invaded 
by erysipelas, and in the ulcerated cavities of the pustules and bullae 
that constitute the eruption. During the evolution of these cutaneous 
disorders, the characteristic symptoms of glanders are developed in the 
nasal passages. The mucous membrane swells, a sensation of obstruc- 
tion is experienced in the posterior nares, and a muco-purulent dis- 
charge streaked with blood excoriates the nostrils and upper lip, or 
finds its way backward into the pharynx. The nose swells and be- 
comes painful, the conjunctiva? become inflamed, ulceration invades the 
nasal cavities, the pharynx, tonsils, and the larynx. The cavity of the 
mouth may also become involved in the same manner. There is cough 
and an expectoration of fetid matter. The lungs may be invaded by 
lobular pneumonia, or by an hypostatic congestion of the inferior por- 
tions. Vomiting and diarrhoea, with offensive stools, are frequent, and 
the spleen is sometimes enlarged. The temperature is rarely excessive, 
but it may rise to 106° or 107° F. The fever is irregular and remit- 
tent, as in other fevers attended by suppuration. The pulse is weak, 
rapid, and irregular. A trace of albumin may be discovered in the 
urine. The nervous system gives evidence of great prostration and 
disturbance. Delirium frequently exists, or the patient exhibits a dull 
and vacant appearance, as in typhoid fever. Convulsions sometimes 
occur, and in the majority of cases death, preceded by stupor and 
coma, terminates the disease in the course of a few days. If preceded 
by the chronic forms of glanders, or by farcy occurring as an indepen- 
dent affection, it generally continues for three or four weeks. 



GLANDERS — FARCY. 195 

4. Chronic Glanders. The essential feature of this variety of glan- 
ders is ulceration in the nasal passages and respiratory tract. It usu- 
ally occurs as the sequel of chronic farcy. In addition to the symp- 
toms that characterize the introduction of the other varieties of the 
disease, there is cough, pain in the throat, and a most distressing 
obstruction of the nose. There is not the swelling and appearance of 
active inflammation that are present in acute glanders, but there is a 
constant obstruction, involving most frequently the left nasal passage. 
It becomes necessary to clear the nose more frequently than usual. 
The matter thus discharged is muco-purulent, thick, and streaked with 
blood, giving evidence of ulceration. The ulcers are seldom visible, on 
account of their location in the upper and lateral portions of the nasal 
cavities. Similar ulcerations sometimes exist in the mouth and pharynx, 
the voice becomes altered in character, it is difficult to swallow, and the 
patient is continually expectorating thick and bloody matter. There 
is a harassing cough, accompanied by abundant expectoration of blood- 
streaked mucus. Occasionally the bronchial tubes or the lungs may 
become inflamed. The sub-maxillary glands are seldom enlarged, and 
there is no eruption upon the skin. Abscesses, however, appear upon 
the surface of the body, as in farcy. Articular and muscular pains are 
more pronounced in chronic glanders than in other varieties of the 
disease. The general symptoms resemble those observed in chronic 
farcy ; fever, gradual exhaustion, anaemia, nausea, diarrhoea, and mani- 
fold nervous disturbances mark the slow progress of the disease toward 
its fatal termination. Its duration may occupy many months, and 
death may sometimes be preceded by the symptoms of acute glanders. 

Diagnosis. The disease is frequently obscure and difficult of recog- 
nition. It should be suspected when patients who have had the care 
of horses present any of the symptoms that have been detailed. Some- 
times, however, the autopsy alone can clear up the diagnosis. It is 
particularly obscure when the disease has been produced by general 
infection without prior local manifestations. It may frequently be mis- 
taken for acute articular rheumatism or for typhoid fever. Careful 
observation of the temperature, however, suffices to differentiate typhoid 
fever. The diarrhoea of fever usually commences early, while that of 
glanders does not appear until the last stage of the disease. 

Articular rheumatism presents more difficulties, but the course of the 
disease and the occurrence of abscesses, ulcers, and naso-pharyngeal 
lesions should suffice to distinguish glanders. 

Facial erysipelas may resemble that which is observed in the last 
stages of glanders, but the previous history and the cutaneous eruptions 
mark a decided difference between the two diseases. 

In like manner the concomitant symptoms, the irregularity of the 
form and appearance of the pustules and bullae, should distinguish the 
eruption of glanders from that of smallpox. 

Syphilis presents many points of resemblance with glanders, but the 
characteristic pains of syphilis have their seat in the bones, and not in 
the muscles or in the joints, and they are especially aggravated at 
night. Gummy tumors develop slowly, and are generally observed 
upon the tibiae, sternum, clavicles, and cranium. They do not contain 



196 PARASITIC AND INFECTIVE DISEASES. 

the sanious pus that fills the abscesses of glanders. When syphilis 
attacks the nose it rapidly destroys the bones, producing collapse and 
deformity of the organ, but the nasal lesions of glanders involve the 
bony structures in a very slight degree. Certain superficial ulcerations 
of the naso-pharyngeal mucous membrane do sometimes, however, 
closely resemble the simple ulcerations of glanders. The ulcerations 
that occur in the mouth, pharynx, and larnyx or trachea, in both dis- 
eases resemble each other so closely that the previous history of the 
patient and other concomitant symptoms must be taken into considera- 
tion in the determination of the diagnosis. 

Tubercular ulcerations present a similar character, but may be dif- 
ferentiated by examination of the bacilli that characterize the disease. 

Prognosis. Few patients who have been attacked with glanders 
escape death. So long as the disease is limited to the lymphatic struc- 
tures there may be hope of recovery, but the appearance of general 
symptoms and the manifestations of the acute variety of the disease are 
almost invariably followed by death. 

Pathological Anatomy. Besides the lesions already described the 
autopsy may exhibit a certain amount of suppurative inflammation of 
the bones, multiple abscesses in the muscles, diffuse suppuration in the 
articulations and veins, deposits of pus in the lungs, or. in certain cases, 
the characteristic appearances of pneumonia, swelling of the spleen, fatty 
degeneration of the liver, and catarrhal inflammation of the kidneys. 
The testicles and the parotid gland are sometimes also the seat of sup- 
puration. In fact, the lesions thus discovered are very similar to the 
phenomena that are presented after death from purulent inflammation 
and pyaemia, being dependent, no doubt, upon the coincident activity 
of the micrococci that produce such inflammations, together with the 
specific bacilli of glanders. 

Treatment. The point of inoculation should be immediately de- 
stroyed by cauterization with the most active agents, such as the actual 
cautery, acid nitrate of mercury, or fuming nitric acid. If treatment 
has been deferred until the lymphatic vessels show signs of inflamma- 
tion, the affected part must be treated as if it were the seat of a dis- 
secting wound. Local bleeding, poultices, and inunction with mer- 
curial ointment, with active tonic medication and alcoholic stimulants, 
comprise the most efficient agents that can be recommended. When 
the disease is fully developed the local lesions must be disinfected and 
treated in accordance with the general principles of surgery. The nasal 
passages and the pharynx should be injected three or four times a day 
w T ith non-poisonous disinfectant solutions, such as boric acid or per- 
manganate of potassium : carbolic acid in solution may be employed as 
far as possible without exposing the patient to the risk of swallowing 
any considerable quantity of the drug. During the acute stage of the 
disease, alcoholic stimulants and opiates must be employed in quantity 
sufficient to support the failing strength, and to quiet the agitation of 
the nervous system. Tonic remedies are useless except in the chronic 
varieties of the disease. Preparations of iodine and sulphur have been 
recommended ; inunction with mercurial ointment has been thought 
beneficial. The tinctures of iron. Fowler"s solution, nux vomica, and 



SYPHILIS. 197 

strychnine have all been tried with occasional good results, though too 
often of a merely temporary character. Iodide of potassium, sulphur, 
and the strong sulphur waters are probably the most useful consti- 
tutional remedies that can be employed. 



CHAPTEE XIII. 

SYPHILIS. 

For complete information regarding the nature, symptoms, mode of 
infection, and course of syphilis, the student is referred to the special 
monographs and surgical text-books that deal with this subject. For 
the purpose of the present volume it will be sufficient to consider those 
tertiary forms of the disease that manifest themselves principally in 
the internal organs of the body. 

Syphilis is one of the most virulent and infective of the communicable 
diseases. Introduced through any solution of continuity or even by 
transudation through the layers of the skin, the invasion of the conta- 
gion is characterized by a period of incubation that continues about 
twenty-five days, more or less. The initial ulcer then appears, which, 
by its hardened base, indicates the fact of general infection. The 
neighboring lymphatic glands rapidly participate in the process of 
inflammatory induration, and enlargement, and in the course of a few 
weeks the secondary period of the disease is fully established. This is 
characterized by the appearance of various eruptions upon the cutane- 
ous and mucous surfaces of the body. These eruptions are either 
erythematous, papulous, squamous, vesicular, or pustular. The most 
characteristic lesion during this period is the condyloma, a modification 
of the papular form, which is usually developed around the orifices of 
the body and upon the mucous membranes. The condylomatous 
patches originate in papular elevations constituted by infiltration of 
the skin with round cells and by proliferation of its papillae. By the 
confluence of neighboring condylomata, broad, flattened, and slightly 
elevated prominences are produced, that are covered with moistened and 
softened epidermal cells. Where opposite folds of the skin are placed in 
contact, the growth of a condyloma upon one surface is soon followed 
by the appearance of a corresponding lesion upon the other, through 
direct local infection. Wherever moisture finds access to a condyloma- 
tous patch the superficial epidermis becomes macerated, and a copious 
exudation oozes from the unprotected vessels of the papular mass. 
For this reason the condyloma is one of the most dangerously infective 
lesions in syphilis. 

Besides the forms of eruption above mentioned, ulceration about the 
nails and between the toes is frequently observed. The nails them- 
selves may become diseased, and in like manner the hair is loosened 
and falls off. Sometimes the skin becomes extensively pigmented. 



198 PARASITIC AXD INFECTIVE DISEASES. 

In other cases the cutaneous surface is deprived of its normal pigment, 
and patches of leucoderma make their appearance. Occasionally the 
integument becomes inordinately thickened. 

The fascice, tendons, muscles, and joints often become painful and 
sensitive to pressure. Sometimes the periosteum of the bones under- 
goes inflammation. Iritis and various forms of choroiditis may invade 
the tissues of the eye. Severe neuralgic pains are not uncommon, 
and in many cases anaesthesia exists in the extremities, especially in the 
hand or forearm. The bones also become sensitive, either as a con- 
sequence of periostitis or by reason of actual inflammatory changes 
involving the osseous tissue itself. 

The secretions from condylomata and from all other secondary 
lesions of syphilis are highly infective. The contagion exists also in 
the blood, in the seminal fluid, and in the ovum ; but the other 
physiological secretions do not contain the poison unless contaminated 
by mixture with pathological products. The nature of the contagion 
is unknown, though it is probably of bacterial origin. 

The tertiary symptoms of syphilis are frequently prevented from 
development by a judicious and energetic course of treatment during 
the secondary period of the disease ; but no person who has been once 
infected can be regarded as positively secure against tertiary manifesta- 
tions, since they often appear after many years of apparently perfect 
health and freedom from every syphilitic symptom. Sometimes they 
are developed, even without the previous manifestation of secondary 
phenomena, or after the occurrence of secondary symptoms of a charac- 
ter so insignificant that they had escaped the observation or memory 
of the patient. The evolution of tertiary phenomena is very often 
dependent upon the occurrence of injuries or other causes that deterior- 
ate the health and depress the natural vigor of the organism. Those 
organs or portions of the body which have been overworked or damaged 
by injury or by other diseases are especially liable to the invasion of 
tertiary syphilis. 

The characteristic lesion of tertiary syphilis is the gumma or gummy 
tumor, which may develop in any of the different tissues and organs of 
the body. It consists essentially of a chronic inflammatory process, 
characterized by an abundant exudation of small round cells that 
separate and encroach upon the normal elements of the affected part, 
occasioning partial obliteration of its bloodvessels and interference with 
the lymphatic circulation. In the tumors that are thus produced there 
is a tendency to final necrosis of the structure and ulceration of the 
adjacent tissue. In this way gummy tumors that are situated in the 
skin and subcutaneous connective tissue become the bases of ulcerative 
processes that are manifested upon the surface in the form of sores, 
that are covered with conical, laminated scabs, like limpet-shells piled 
one upon another (rupia). Frequently the ulcers that have been thus 
formed extend themselves along one margin, while the healing process 
goes on upon the other. In this way serpiginous sores of a horseshoe 
form are developed. The process of cicatrization is always accompanied 
by considerable loss of cutaneous substance, so that a conspicuous scar 
is formed. For a long time this remains deeply pigmented, or, after a 



SYPHILIS. 199 

considerable period, may exhibit a white centre surrounded by a border 
of brown pigment. Such ulcers frequently produce deformity of the 
lips, nostrils, ears, eyelids, and other conspicuously retractile portions 
of the skin. 

Grummy tumors do not always ulcerate, but frequently undergo 
gradual absorption and final disappearance. The infiltrated tissue, 
however, is in great measure destroyed during this process, so that the 
site of the cutaneous tumor may be easily recognized by a depression 
in the skin and subjacent substance. 

The muscles, together with their sheaths, tendons, and bursse, are 
sometimes invaded by gummatous growths. These sometimes involve 
the connective tissue in the form of diffuse infiltration, sometimes in 
the form of a circumscribed tumor. The contractile substance of the 
muscle undergoes degeneration and absorption as a consequence of the 
pressure that is thus maintained. Sometimes suppuration and evacua- 
tion of the mass takes place, but frequently it is gradually absorbed, 
like the corresponding cutaneous tumors, and the muscles become dis- 
abled by the consequent loss of substance and induration of the adjacent 
tissues. In this way contracture and deformity may be produced. 

The joints are not unfrequently damaged by the formation of gummy 
tumors in the articular extremities of the bones or in the subserous 
substance of the articulation itself. Painful swelling, like that of acute 
rheumatism, may be thus produced, and may be followed by suppura- 
tion, by ankylosis, and by general destruction of the articular 
mechanism. In milder forms of the disease simple chronic distention 
of the joint with a serous transudate may be the principal symptom 
of the disease. 

The bones are frequently invaded by syphilitic inflammation at an 
early period of the disease, and during its tertiary stage gummy 
tumors often develop either in the periosteum or in the bone-marrow. 
In either case their growth results in destruction of the osseous sub- 
stance, producing a fragility of the bones that sometimes renders them 
especially liable to fracture. Those portions of the skeleton that lie 
immediately beneath the skin appear to be the favorite seats of gumma- 
tous infiltration. It is, therefore, not uncommon to discover swelling and 
tenderness upon the bones of the cranium, upon the collar-bone, the ribs, 
the shoulder-blades, the sternum, and the prominent surfaces of the ulna, 
radius, tibia, and fibula. In many cases these superficial gummata ulcer- 
ate and penetrate the overlying skin, so that the necrotic bone is readily 
visible through the openings that are thus produced. Extensive ulcera- 
tion of the cranial bones is sometimes witnessed, exhibiting the genuine 
"raw head and bloody bones " of vulgar narrative. Sometimes exten- 
sive necrosis is followed by exfoliation and discharge of considerable 
portions of the cranial vault. The absorption of a periosteal gumma is 
frequently followed by the formation of a palpable depression in the 
bony surface, and the overlying skin becomes firmly adherent over its 
entire extent. Sometimes the infiltrated bone undergoes calcareous 
degeneration that results in consolidation and eburnation of the pre- 
viously inflamed and disorganized structure. 

The processes that accompany syphilis of the bones are extremely 



200 PARASITIC AND INFECTIVE DISEASES. 

tedious and painful. Though not particularly dangerous to life, they 
frequently result in conspicuous deformity and serious crippling of the 
patient. When attended by prolonged suppuration there is always 
danger of intercurrent amyloid degeneration in other tissues and 
organs. It is not always easy to distinguish between tubercular and 
syphilitic lesions of the bones, unless it be possible to discover the 
presence of tubercle bacilli or to produce a characteristic febrile 
reaction by the hypodermic injection of tuberculin. 

Syphilis of the Nose — Syphilis Nasi. 

Symptoms and Diagnosis. Tertiary lesions involving the nose are 
of a gummatous nature, and may originate either in the external cuta- 
neous investment, or in the mucous lining of the organ, or may take 
their point of departure from the substance of the nasal cartilages and 
bones. 

Cutaneous gummata may be easily mistaken for lupus or for can- 
cerous diseases of the nose. When the mucous membranes are invaded,, 
severe ulceration, obstruction of the nasal passages, and a copious, 
offensive discharge are the principal symptoms. It is not often that 
the nasal cartilages are primarily invaded, but when they become 
ulcerated the septum of the nose may be perforated or wholly destroyed, 
so that the nostrils are transformed into a single, irregular chasm that 
opens into the depressed, retracted, and deformed stump of a snout, 
giving a hideous aspect to the formerly regular and agreeable features 
of the countenance. 

Gummatous inflammation of the nasal bones may involve any portion 
of their structure, resulting in more or less extensive loss of substance 
and consequent deformity of the nose. The ulcerative process may 
extend upward into the cavity of the cranium, producing fatal menin- 
gitis ; but it more frequently involves the bones of the hard palate, and 
produces a characteristic perforation of the roof of the mouth. In this 
way great interference with the functions of deglutition and of speech 
may be established. Liquids can be no longer excluded from the nasal 
cavity during the act of swallowing, and the voice assumes a peculiarly 
indistinct and nasal character. The ulcerative process is usually ac- 
companied by great pain, considerable swelling of the soft parts, a 
horribly offensive discharge (ozaena syphilitica), and often by the ex- 
foliation of considerable fragments of the diseased bones. 

Treatment. The general treatment consists in the administration 
of iodide of potassium (potass, iodid. §ss, aquae 5vj. Sig. A teaspoonful 
in half a glass of water after each meal), and in the use of mercurial 
inunctions. Mercurial ointment should be rubbed into the skin after a 
warm bath at bedtime. The skin should be thoroughly cleansed with 
soap, and the ointment may be rubbed, at first, upon the inner surface 
of one leg ; the next day upon the opposite leg ; then upon the inner 
surface of one of the thighs ; the next day upon the other ; then upon 
the inner surface of one of the upper arms ; then upon the other ; and 
lastly upon either side of the thorax ; after which the round may be 
commenced again upon one of the lower extremities. In this way irri- 



LARYNGEAL SYPHILIS. 201 

tation of the cuticle through excessive friction may be avoided. Hairy 
portions of the body will not tolerate any considerable amount of 
friction, since the roots of the hairs are liable to inflammation when 
thus severely treated. The mouth should be carefully guarded during 
the period of inunction by attention to the condition of the teeth, and 
by frequent gargling with a five per cent, solution of chlorate of potas- 
sium. Smoking must be interdicted, since it favors the occurrence of 
mercurial stomatitis. The diet must be abundant, but of an unexciting 
character. Alcoholic stimulants, spices, and rich sauces must be for- 
bidden. The clothing should be warm, and moderate exercise in the 
open air may be encouraged, though all exposure to wet and cold must 
be avoided. 

In addition to the general treatment above indicated, local applica- 
tions are indispensable. If the external surfaces are ulcerated, great 
benefit will be derived from the application of adhesive plasters thickly 
spread with mercurial ointment. When the nasal passages are obstructed 
by the products of inflammation, nasal douches containing two per cent, 
of carbolic acid, or corrosive sublimate (1 : 1000). Diluted Listerine, 
and a solution of boric acid, or of permanganate of potassium, may be 
also employed. Having thus thoroughly cleansed the diseased surfaces, 
they should be brushed with iodized glycerin (potass, iodid. 10 parts 
iodini cryst. 1 part, glycerin 100 parts), or they may be thoroughly 
powdered with iodoform, or with calomel and alum in equal parts. The 
ultimate deformity that sometimes follows extensive necrosis requires 
surgical measures for its removal. 

Laryngeal Syphilis — Syphilis Laryngis. 

Symptoms and Pathological Anatomy. Laryngeal disease is fre- 
quently one of the early consequences of the secondary form of syphilis, 
but it also may exist as a tertiary lesion many years after the original 
infection. It may occur among children as a symptom of hereditary 
syphilis, but it then manifests no special difference from the laryngeal 
syphilis of adults. By the aid of the laryngoscope it is possible to 
recognize slight changes in the laryngeal mucous membrane, even 
before any noteworthy symptoms are furnished from other sources. 
Among the earlier forms of laryngeal syphilis are catarrhal inflamma- 
tion and condylomata of the mucous membrane ; among the later forms 
of the disease, gummatous swellings are the most conspicuous. These 
lesions constitute the primary forms of syphilis in the larynx. Sec- 
ondary ulceration of the infiltrated structures not unfrequently occurs, 
and produces extensive destruction of the laryngeal membranes, carti- 
lages, and vocal cords. Deformity and stenosis of the laryngeal pas- 
sages are the usual consequences of such ulceration. Sometimes oedema 
of the glottis is developed, and suffocation may be produced by pro- 
gressive contraction of the laryngeal orifice. 

Syphilitic catarrh of the larynx presents no visible appearances that 
differ from those which accompany ordinary inflammation of the laryn- 
geal mucous membrane. The disease is, however, of a more persistent 
character ; and when the vocal cords are involved, a peculiar hoarseness 



202 PARASITIC AND INFECTIVE DISEASES. 

that is suggestive of its origin forms a very noticeable symptom. In 
many cases, however, only the ordinary disagreeable sensations of 
tickling, burning, and inclination to cough accompany the laryngeal 
disorder. 

Conclylomatous 'patches, similar to those which develop in the 
pharynx, frequently occur upon the vocal cords, upon the arytenoid 
cartilages, and posterior wall of the larynx. If left without treatment, 
these patches are very liable to ulceration. 

Among the tertiary symptoms of syphilis are laryngeal gummata. 
Their favorite seat is upon the epiglottis, though they are also observed 
upon the vocal cords and elsewhere. They exist either in the form of 
circumscribed tumors of variable size, or as a considerable infiltration of 
a diffuse and irregular character. They may produce laryngeal stenosis, 
either during the stage of infiltration, or as a consequence of cicatricial 
contraction. During the ulcerative stage serpiginous ulcerations gradu- 
ally develop, and slowly eat their way into the tissues of the organ. 

The principal danger in laryngeal syphilis consists in the tendency 
to oedema during the period of ulceration, and to suffocation as a con- 
sequence of progressive stenosis during the period of cicatrization and 
contraction. Dangerous hemorrhage occasionally occurs during the 
period of ulceration. Suffocation is rarely produced by the entrance of 
food into the larynx after destruction of the epiglottis, since the laryn- 
geal orifice is sufficiently occluded, during the act of deglutition, by 
the false vocal cords and by the retracted base of the tongue. 

Diagnosis. The diagnosis of laryngeal syphilis is sometimes ren- 
dered difficult by the absence of other syphilitic lesions, and by the lack 
of veracity or knowledge on the part of the patient. So great is the 
similarity between the laryngeal lesions of syphilis and tuberculosis 
that, in such cases, the diagnosis of syphilis must rest upon the exclu- 
sion of the symptoms of tuberculosis in the lungs, and upon the 
absence of tubercle bacilli from the laryngeal exudations. The laryn- 
geal lesions of leprosy are associated with pronounced symptoms of the 
disease upon the external surface of the body. Cancerous disease of 
the larynx can be with difficulty distinguished from syphilis. Its 
course is usually more painful and rapid than that of syphilitic disease. 
When tuberculosis and syphilis are combined in the same patient, a 
differential diagnosis is impossible. 

Prognosis. The prognosis in cases of laryngeal syphilis is always 
attended with gravity, especially when treatment has been neglected or 
postponed. Even after recovery from the active process of disease 
there is great danger of progressive stenosis that may necessitate trache- 
otomy and a permanent use of a tracheal canula. 

Treatment. The treatment of laryngeal syphilis must be both 
general and local. The course of general treatment has been already 
described. Local treatment in the catarrhal forms of the disease con- 
sists in the inhalation of a pulverized solution of corrosive sublimate 
(0.01 : 100). Laryngeal condylomata should be treated with daily 
insufflations of calomel and powdered gum-arabic (2 : 3). Ulcerated 
gummata should be painted every day with iodized glycerin, or the 



PULMONARY SYPHILIS. 203 

patient may be made to inhale the pulverized aqueous solution of iodide 
of potassium (1 : 200). 

Tracheal and Bronchial Syphilis — Syphilis Tracheae et 
Bronchorum. 

The trachea and bronchi are occasionally the seat of syphilitic lesions 
identical with those which have been already described in the laryngeal 
tissues. Catarrhal inflammation, condylomata, and gummatous ulcera- 
tion may exist in circumscribed portions of the tracheal or bronchial 
passages ; but sometimes the entire extent of the respiratory tract is 
occupied by the disease. Great irritation, cough, and expectoration 
usually accompany the morbid process. Sometimes, however, the 
course of the disease is exceedingly insidious, and conspicuous symp- 
toms only appear when constriction of the air passages has been estab- 
lished. Sometimes the lungs are infected by the passage of morbid 
secretions into the alveolar passages and air cells, producing catarrhal 
pneumonia, abscess, or gangrene of the lungs. 

The treatment of tracheal syphilis does not in any respect differ 
from that of the laryngeal variety of the disease. 

Pulmonary Syphilis — Syphilis Pulmonum. 

Pathological Anatomy. Pulmonary syphilis exists in two forms : 
either as a diffuse infiltration, or as circumscribed gummy tumors in the 
substance of the lungs. 

Pulmonary infiltration of a syphilitic origin usually occurs in the 
middle lobe of the lungs. The right lung appears to be affected more 
frequently than the left. The infiltrated portion is firm, dry, and of a 
yellowish-gray color, closely resembling the appearance of a pneumonic 
lung in the stage of gray hepatization. The exudation chiefly involves 
the interstitial tissue of the organ, but the epithelial cells of the alve- 
olar spaces frequently undergo a process of infiltration and fatty degen- 
eration. According to some observers, the principal seat of disease is 
located in the alveolar spaces. The endothelial layer of the lymph 
vessels is also invaded, and the lymph passages are more or less 
obstructed by cellular proliferation and by degeneration of the lymph 
corpuscles. When suppuration occurs, cavities are formed in the lung 
substance, just as they occur in the analogous conditions presented by 
pulmonary tuberculosis. The healing process is also followed by cor- 
responding changes in the adjacent connective tissue, and by cicatricial 
contraction. 

Pulmonary gummata differ chiefly from the above-described form of 
infiltration in the fact that they present a clearly defined and circum- 
scribed mass. Such tumors may also undergo softening and suppura- 
ration, resulting in the formation of a cavitv, and in favorable cases 

7 O v ' 

cicatrization and recovery may occur. 

Brown induration of the lungs, similar to that which has been 
observed in connection with cardiac disease, sometimes occurs as a con- 
sequence of syphilis. 



204 PARASITIC AND INFECTIVE DISEASES. 

The pleura is sometimes invaded when syphilitic infiltrations or 
gummata involve the superficial portions of the lung. Occasionally the 
pleura becomes greatly thickened and contracted as the result of an 
independent syphilitic process. 

Symptoms and Diagnosis. It sometimes happens that pulmonary 
syphilis manifests few and insignificant symptoms, so that the disease 
is only accidentally discovered. In the majority of cases the symptoms 
correspond with those of pulmonary tuberculosis. Tubercle bacilli are, 
however, absent from the sputa. 

Prognosis and Treatment. When the cause and nature of the 
diseased tumors are early recognized, a tolerably favorable prognosis is 
rendered possible. The treatment must be conducted in accordance 
with the general rules already laid down on page 200. 

Syphilis of the Alimentary Canal — Syphilis Tr actus Intestinalis. 

Symptoms. During the secondary stage of syphilis, erythematous 
and conclylomatous eruptions frequently exist within the cavity of the 
mouth, which may thus become painfully ulcerated. Besides these 
manifestations upon the tongue, in the tertiary stage of the disease, 
gummy tumors are frequently developed in that organ. These closely 
resemble the infiltrations that are produced by cancer and by tubercu- 
losis, but they are less frequently accompanied by induration of the 
adjacent lymph glands. They are usually solitary, and yield not unfre- 
quently to energetic anti-syphilitic treatment. It was formerly sup- 
posed that certain fissured appearances of the tongue, and certain 
white, scaly patches upon its upper surface were caused by syphilis, 
but it is now well known that such lesions have no necessary connection 
with that disease. 

Grummy tumors often develop in the roof of the mouth, in the fauces, 
and in the pharynx. By their ulceration the uvula may be destroyed, 
and adhesion may take place between the soft palate and the posterior 
wall of the pharynx, so as to occlude more or less completely the naso- 
pharyngeal passages. When such tumors originate in the periosteum, 
the bones of the roof of the mouth are often invaded, and perforation of 
the hard palate may result in the formation of a communication between 
the cavity of the mouth and the nasal passages above. Sometimes the 
ulcerative process results in fatal hemorrhage from erosion of the inter- 
nal carotid or other large bloodvessels in the neighborhood of the 
pharynx. Sometimes the salivary glands become indurated, and if the 
oesophageal walls are attacked, ulceration and cicatricial stenosis of the 
oesophagus are produced. 

Gummatous infiltration of the gastric walls has been known to 
occur, and it is probable that ulceration of the stomach may be some- 
times thus produced. In the same way the mucous membrane of the 
intestine is occasionally invaded, producing the symptoms of intestinal 
ulceration, and sometimes leading to perforation and peritonitis. It is 
probable that the diarrhoea which is sometimes observed in syphilitic 
patients, and is cured by mercurial treatment, is the result of syphilitic 
catarrh of the intestines. 



HEPATIC SYPHILIS. 205 

The rectum is often the seat of gummatous infiltration and ulceration. 
The symptoms resemble those of dysentery, and exploration of the pas- 
sage with the finger discovers the existence of ulceration, induration, 
and cicatricial contraction of the parts. 

Treatment. The general treatment of syphilis must be associated 
with such local applications and anodynes as are needed for the relief 
of pain, and for stimulation of the ulcerated surfaces. 

Hepatic Syphilis — Syphilis Hepatis. 

Syphilitic disease of the liver is usually encountered during the ter- 
tiary stage, or as one of the consequences of hereditary syphilis. 

Pathological Anatomy. Hepatic syphilis manifests itself in a 
variety of forms. It may produce syphilitic perihepatitis, in which the 
serous investment of the organ is thickened and becomes adherent to 
the neighboring organs ; or it may occasion a diffuse interstitial inflam- 
mation of the interlobular connective tissue by which the parenchyma 
of the organ is destroyed. The liver may be also invaded by gumma- 
tous inflammation, which occurs in two forms : a miliary infiltration, 
and the ordinary larger gummatous tumors. The miliary gummata 
exist as numerous minute yellow masses scattered throughout the liver. 
They consist of round cells connected with the walls of the bloodvessels, 
biliary passages, and lymph canals. By their aggregation and coales- 
cence ordinary gummy tumors may be constituted. These vary from 
the size of a pea to that of an orange. They are generally found in 
the neighborhood of the suspensory ligament, and upon the lower border 
of the liver. The newly formed tumors consist chiefly of round cells, 
and present, on incision, a reddish-brown color ; but at a later period 
of their growth they frequently undergo caseation, and sometimes sup- 
puration, resulting in the formation of an abscess from which the soft- 
ened contents of the tumor may find their way into the neighboring 
bile ducts. Sometimes, however, the process of degeneration is termi- 
nated by calcification of the mass. 

When gummy tumors extend to the surface of the liver and branch 
out extensively into its substance, their degeneration and cicatrization 
is followed by irregular contraction and consequent deformity of the 
organ, so that in advanced cases of syphilitic disease the contracted 
liver appears as if cloven into numerous lobulated masses. 

Cirrhosis and amyloid degeneration of the liver may have their origin 
in syphilitic disease, but in other respects these forms of syphilitic 
degeneration do not differ from ordinary cirrhosis and amyloidosis. 

Symptoms and Diagnosis. Syphilis of the liver often pursues 
a course so insidious and so little accompanied by pain that the exist- 
ence of the disease is only discovered after death. When symptoms of 
hepatic disorder exist, they are so varied and so like the symptoms of 
ordinary hepatic disease that their reference to a syphilitic source is 
often only a matter of inference from the fact of previous syphilitic 
manifestations in other organs of the body. 

Prognosis and Treatment. The prognosis in cases of hepatic 
syphilis is ordinarily unfavorable, since recovery from the active symp- 



206 PARASITIC AXD INFECTIVE DISEASES. 

torus of disease may still be followed by the consequences of cicatricial 
contraction and interference with the function of the hepatic cells, and 
with the outflow of bile. 

The treatment consists chiefly in the administration of iodine and its 
compounds. Mercurials must be used with considerable caution. Hot 
baths and brine baths and saline mineral waters may also be used with 
advantage. 

Syphilis of the Spleen — Syphilis Lienis. 

The spleen is frequently invaded by syphilitic disease. In the early 
stage the organ is acutely enlarged, as it is in so many other infective 
liseases, and so long as it remains enlarged the patient is liable to 
relapses, but under proper anti-syphilitic treatment the tumor finally 
disappears. 

During the later stages of syphilis the spleen frequently under." - 
chronic interstitial inflammation, involving the connective tissue. The 
organ becomes enlarged and indurated, and its surface is frequently 
adherent to the neighboring organs. Similar changes are observed as 
a consequence of congenital syphilis. 

During the tertiary stage of si/pJdlis gummy tumors of various size 
are often developed in the spleen, where they undergo caseation, and if 
absorbed give origin to cicatricial contraction and consequent deformi- 
ties of the organ. 

For remedial agents the iodides are to be preferred. 

Renal Syphilis — Syphilis Renum. 

All forms of renal disease may be produced by syphilis, and there 
is nothing by which the ordinary renal diseases can be differentiated 
from those of syphilitic origin, unless it be the fact that there is often 
a greater amount of proliferation in the connective tissue when the 
inflammation is of a syphilitic character, and that the subsequent re- 
traction and deformity of the kidney is considerably greater than in 
cases of ordinary interstitial nephritis. Occasionally gummy tumors 
develop in the kidneys. These may be either of miliary dimensions or 
of larger size, and they differ in no essential particular from the similar 
manifestations in other organs. They may either undergo caseation or 
rption. with subsequent contraction and deformity of the organ. 

Syphilis of the Sexual Organs. 

The epididymis is rarely involved in syphilitic disease unless the tes- 
ticle is at the same time invaded. The same thing is also true of the 
vas deferens, the vesieuhe seminales. and the prostate gland. In the 
testicle the tunica albuginea is frequently thickened. Sometimes the 
interstitial connective tissue of the organ is the principal seat of pro- 
liferation, and sometimes gummy tumors make their appearance in the 
substance of the organ. Unlike similar cancerous infiltrations, gummy 
tumors are not sensitive to pressure, nor are they accompanied by 
degeneration of the inguinal lymph glands. Tuberculosis also differs 



CEKEBRAL SYPHILIS. 207 

from syphilis in the fact that it commences always in the epididymis. 
When gummy masses undergo a softening and suppuration the ordinary 
phenomena of abscess formation and evacuation are presented. 

Syphilitic Disease of the Vascular Organs. 

The muscular substance of the heart may be invaded by gummy 
masses or by diffuse infiltration of syphilitic origin, greatly interfering 
with the function of the cardiac muscle. When the endocardium is 
involved it becomes considerably thickened, and valvular lesions may 
be thus produced. 

Gummy indurations sometimes invade the pericardium, and may 
excite inflammation of its surface. 

Syphilis sometimes produces arterio-sclerosis of the larger arteries, 
thus laying the foundation of future aneurismal growths. Even more 
important are the effects of syphilitic endarteritis upon the smaller 
arteries of the body. Sometimes thickening and induration of the 
vascular walls proceed so far as to produce actual occlusion of the 
affected vessels. Gangrene of the tissues, thus deprived of their blood 
supply, has been observed. 

Cerebral Syphilis — Syphilis Cerebri. 

Etiology. Under the term cerebral syphilis are grouped all those 
syphilitic diseases which involve not only the substance of the brain, 
but its bloodvessels and membranes. In many instances the cerebral 
lesions are associated with or follow syphilitic diseases in the cranial 
bones. In this way abscesses may be produced in the brain, or com- 
pression of the cranial nerves may take place in the bony canals 
through which they pass toward the periphery. 

The brain is one of the most common seats of visceral syphilis. In 
the majority of cases it is during the tertiary stage of syphilis that 
cerebral lesions are produced, so that their occurrence may date many 
years subsequent to the initial infection. This rule, however, is not 
without exceptions, so that in certain cases cerebral disorders follow 
rapidly after the manifestation of the secondary symptoms of syphilis. 

Among the predisposing causes of cerebral syphilis is the existence 
of a neurotic constitution, leading to speedy exhaustion of the brain 
when that organ is subjected to fatigue, excitement, injury, or other 
forms of disease. Exhaustion, debauchery, concussion, or other injuries 
of the brain, inefficient treatment of syphilis in its early stages, and 
the premature development of the tertiary stage, all seem to act as 
predisposing causes of cerebral syphilis. 

Syphilitic disease of the brain is obviously more common among 
adults, yet children who have inherited syphilis sometimes exhibit 
evidences of its location within the cranium. 

Pathological Anatomy. Intra-cranial syphilitic lesions usually 
commence in the bloodvessels and membranes of the brain. It is 
probable that when the cerebral substance itself is invaded, the process 
commences either in the meninges r in the bloodvessels. In the 



208 PARASITIC AXD INFECTIVE DISEASES. 

meninges the morbid process takes the form of gummatous growth, 
usually from the dura mater, and also from the subarachnoid tissue. 
Originating between the two layers of the dura mater, the gummy mass 
may develop outward, or may press inward into the brain itself. The 
neoplastic formations occur more frequently upon the convexity of the 
brain, often invading the falx cerebri, but are also found in the neigh- 
borhood of the cavernous sinus at the base of the brain. When located 
in this region the third and sixth nerves are frequently subjected to 
pressure, producing paralysis of the ocular muscles. In many instances 
the gummatous growths exist in the form of circumscribed tumors 
which may reach considerable size, though frequently they exhibit the 
form of minute miliary granulations upon the meninges. In other 
cases the morbid process consists in a diffuse infiltration without any 
definite limits, resembling in many respects an ordinary inflammatory 
exudation. In this way thickening and adhesion of the meningeal 
surfaces may be produced. When the process extends into the sub- 
stance of the brain it may finally result in softening, suppuration, and 
extensive destruction of the cerebral tissues. 

When the cerebral arteries become the seat of syphilitic disease, the 
external and middle coats of the vessels are invaded by gummy growths, 
or the inner lining of the vessels is attacked by endarteritis. These 
different processes are most intimately related to each other. Endar- 
teritis may exist alone, though it is frequently excited by disease in the 
outer layers of the vascular wall. These changes are most conspicuous 
in the arteries that contribute to the formation of the circle of Willis, 
especially the basilar artery, the middle cerebral, and Sylvian arteries. 
For this reason symptoms of disease in the pons Varolii, and lesions of 
the third frontal convolution and island of Reil, producing aphasia, are 
frequently encountered in cases of cerebral syphilis. 

The changes thus produced in the arterial walls are plainly visible to 
the naked eye. They consist in an irregular thickening and induration 
of the vascular wall, by which the lumen of the vessel may be more or 
less completely constricted or even totally obliterated. Thrombi fre- 
quently occupy the constricted portions, cutting off the supply of blood 
from those portions of the brain that lie beyond the seat of obstruction. 
In this way softening and paralysis of circumscribed parts of the brain 
may be produced. The gravity of such lesions is greater the nearer to 
the base of the brain they are located. Obstruction of the peripheral 
portions of the cerebral circulation upon the convexity of the brain 
admits of a greater degree of compensation through inosculation of the 
neighboring vessels ; but upon the inferior surfaces of the organ such 
compensation is almost impossible. 

Besides the arterio -sclerotic and endarteritic changes that have been 
described, aneurism may develop upon the cerebral arteries as a conse- 
quence of syphilis. The occurrence of similar diseases in the heart 
and in the large thoracic vessels, may lead to embolic or thrombotic 
obstruction in the brain ; so that syphilis may result in injury of that 
organ either by its direct action, or indirectly through the medium of 
the circulation. 



CEREBRAL SYPHILIS- 209 

Symptoms. The symptoms of cerebral syphilis may be manifested 
either through disorder of the intellectual processes, or through dis- 
turbances of sensation and motion. 

Psychical changes are not uncommon. The patient loses energy, 
becomes forgetful, irritable, despondent, or even completely insane. The 
progressive paresis of the insane often has its origin in syphilis. Some- 
times a species of hypochondria termed syphilophobia may be observed. 
In this disorder the patient is continually occupied with the idea that 
he is a victim of syphilis, though a similar delusion is sometimes mani- 
fested by persons who have never become victims of the real disease. 
In like manner hysteria and neurasthenia sometimes have their origin 
in syphilis. 

In certain cases paroxysms of aphasia are experienced. These may 
continue for a number of hours or for several days, and then terminate 
quite suddenly. Repeated paroxysms of this sort, that are unattended 
by paralysis of the extremities, are especially suggestive of cerebral 
syphilis. They are probably dependent upon disorders of the circula- 
tion in the territory of the Sylvian artery. 

In certain cases overwhelming somnolence occurs. The patient 
lies for many hours or days in a state of more or less profound uncon- 
sciousness, which may be either quiescent or disturbed by delirious 
dreams. The recovery of consciousness is usually gradual, and such 
attacks frequently follow one another with intervals of variable dura- 
tion. Sometimes a condition of profound coma is developed, during 
which the eyeballs are divergent ; reflex movements can no longer be 
excited by touching the conjunctivae, and the tendinous reflexes are 
either greatly diminished or completely abolished. The pulse is fre- 
quently retarded, and the temperature of the body is subnormal. 

In contrast with such cases is the condition of obstinate wakefulness 
that is sometimes experienced by syphilitic patients. This condition 
may exist without any apparent cause, and may be entirely unaccom- 
panied by pain or intellectual excitement. 

In certain cases cerebral syphilis is accompanied by intense headache 
and paroxysms of neuralgia. The headache assumes all the forms that 
characterize ordinary headache, and it sometimes terminates in coma. 
It is usually exaggerated by every kind of bodily or mental excitement 
and fatigue. It is especially severe at night, and its intensity is often 
intolerable, rendering the patient almost insane. Sometimes its sponta- 
neous cessation is so sudden that it can be explained only by the 
hypothesis of circulatory disorder. 

Disturbances of sensation exhibit a great variety of forms, which 
may be circumscribed within very narrow limits, or may be widely 
diffused over many nerve tracts. The nerves of special sense are also 
sometimes involved. When the visual function is thus disturbed, it 
often happens that nothing can be discovered with the ophthalmoscope 
to account for the loss of sight ; but in certain cases endarteritis of the 
central artery of the retina, and syphilitic retinitis, can be demon- 
strated. 

Paralytic symptoms are most frequently observed in connection with 
the cerebral nerves. The oculomotor nerve is the principal sufferer, 

14 



210 PAKASITIC AXD INFECTIVE DISEASES. 

and next in order comes the abducent nerve. Rapid recovery often 
follows the use of iodide of potassium, but relapses frequently occur. 
The cause of these paralyses is usually found in the compression of the 
nerve trunks by gummatous growths at the base of the brain ; but it is 
remarkable how often individual branches of the third nerve escape 
paralysis under such circumstances. 

The facial nerve is sometimes similarly affected. In many cases the 
paralysis is complete, though sometimes only a weakness of the affected 
muscles is apparent. 

Paralytic conditions often occur in the extremities. When there is 
complete paralysis of a hemiplegic character, the tendon reflexes are 
almost always exaggerated upon the paralyzed side. The extent and 
intensity of the paralytic symptoms are exceedingly variable, involving 
sometimes a single extremity, the entire half of the body, or only a 
limited group of muscles. In certain cases the paralytic condition is 
completely developed, while in others, only a paretic weakness of the 
affected muscles is manifested. Sometimes the symptoms appear very 
abruptly, while again they are very slowly developed. Their duration 
is characterized by similar irregular variations. 

The occurrence of apoplectiform seizures is a not uncommon con- 
sequence of cerebral syphilis. The patient may be stricken down 
suddenly, with all the symptoms of an apoplectic attack which may 
terminate fatally, or from w T hich he may recover gradually with more 
or less consequent paralysis, followed by contracture and muscular 
atrophy like what are observed after ordinary cerebral hemorrhage. 
In other cases the patient remains for a long time in a somnolent con- 
dition, from which he gradually recovers, only to be stricken down in 
repeated subsequent attacks. Sometimes the mental faculties are 
greatly disturbed, and delusions dominate the intellectual processes 
and actions of the individual. When the paralysis involves the right 
side of the body aphasic symptoms are frequently observed. 

Among other motor symptoms produced by cerebral syphilis may be 
mentioned epilepsy. This is frequently manifested in the form of 
cortical epilepsy, but in no essential particular does it differ from the 
ordinary forms of the disease. Its first manifestations usually occur 
in middle life. So frequently is this the case that the occurrence of 
a first epileptic attack during middle life should awaken the suspicion 
of a syphilitic origin. 

Chorea, tremor, and dizziness of an obstinate character sometimes 
have their origin in cerebral syphilis, and only yield to antisyphilitic 
treatment. When the floor of the fourth ventricle is invaded the 
phenomena of polyuria, polydipsia, and diabetes are sometimes 
observed. 

Diagnosis. The recognition of cerebral syphilis is comparatively 
easy when the history and symptoms of preceding syphilis can be 
established, but in the absence of these guides great difficulty may 
attend the diagnosis. When dealing with married people it is important 
to ascertain whether the offspring of their union have exhibited 
symptoms of hereditary syphilis ; whether they died early or whether 
they exhibited a predisposition to scrofula or rickets. Childless mar- 



SYPHILIS OF THE SPINAL CORD. 211 

riages, and the occurrence of repeated abortions, are suggestive of a 
syphilitic cause. 

Having gained all the light possible from the above-mentioned con- 
siderations, a review of the symptoms that characterize cerebral syphilis 
will generally guide the observer to an accurate diagnosis. In this 
matter a long experience and wide observation are of the greatest 
value to the diagnostician, who frequently finds himself compelled to 
decide in favor of a syphilitic origin of disease, though he may be 
unable to state in exact terms all the reasons for this instinctive con- 
clusion. In doubtful cases, especially when dealing with patients in 
an urban population, it is wise to assume the probability of a syphilitic 
cause and to prescribe accordingly. 

Prognosis. In every case of cerebral syphilis the prognosis is 
uncertain, for the dangers that attend the disease are numerous and 
grave. Trifling symptoms are often rapidly followed by alarming changes 
and a speedy death. The nearer the lesion is situated with reference 
to the medulla oblongata the greater the danger of a fatal result. 

Treatment. The treatment should be conducted with great energy 
in accordance with the rules already given for the general treatment of 
syphilis. Many physicians prescribe mercury and iodide of potassium 
together, but it is usually preferable to employ active inunctions with 
mercurial ointment for three or four weeks before commencing the use of 
iodide of potassium. Inunctions may be repeated at intervals during the 
whole course of the disease ; and even after the disappearance of symp- 
toms, it is often a matter of prudence to renew the treatment from time 
to time, as a prophylactic expedient. Iodide of potassium should be 
given usually in five-grain doses three times a day, though many 
physicians advise the administration of the drug in doses of one or 
even two drachms three or four times a day. The paralyzed muscles 
may be advantageously treated with electricity and massage, in accord- 
ance with the general principles that regulate the employment of such 
methods. 

Syphilis of the Spinal Cord — Syphilis Mednllse Spinalis. 

It is undoubtedly true that syphilis is the underlying cause in many 
cases of disease of the spinal cord, but it is often very difficult to assign 
any precise value to this or that symptom as evidence of a syphilitic 
origin in any particular case, since apparently identical lesions may 
occur both in syphilitic and in non-syphilitic patients. The results of 
treatment are no more significant, since many diseases of the spinal 
cord that are of a non-syphilitic origin appear to be as much benefited 
by an anti- syphilitic course of treatment as are the cases in which the 
connection with a syphilitic source appears to be unmistakable. 

Pathological Anatomy. Syphilitic diseases of the spinal cord 
are sometimes produced indirectly by the effects of previous disease in 
the bones or meninges of the spinal column. Various osseous tumors, 
gummata, carious processes, exostoses, etc., may result in compression 
of the cord and destruction of its substance, followed by corresponding 
symptoms. 



212 PARASITIC AND INFECTIVE DISEASES. 

But the spinal cord itself may be directly influenced by syphilitic 
processes in its own special substance. With the exception of gumma- 
tous tumors of the cord it is difficult, if not impossible, to distinguish 
syphilitic inflammation, sclerosis, induration, and atrophy, from similar 
lesions of a non-syphilitic character. Thickening of the meninges and 
their adhesion to the cord itself are suspicious circumstances. In cer- 
tain cases the occurrence of endarteritis causes obstruction of the spinal 
vessels, and leads to the formation of minute points of myelitis scattered 
throughout the substance of the cord. Such changes are often associ- 
ated with similar processes in the brain. 

It sometimes happens that severe symptoms of spinal paralysis of an 
acute ascending course, or other formidable diseases of the cord, are mani- 
fested without the possibility of discovering after death any apparent 
changes in the substance of the cord by which the phenomena can 
be explained. Such cases, in the present state of our knowledge, must 
be considered as examples of a purely functional disorder. 

Symptoms and Diagnosis. So great is the number of the symp- 
toms and diseases that may have their origin in syphilitic affections of the 
spinal cord that it is useless to attempt their recital in this place. So 
far as symptoms are concerned, it is impossible to differentiate syphilitic 
spinal diseases from those of a non-syphilitic character, consequently 
the reader is referred to those pages of this volume which treat of the 
symptoms and diagnosis of spinal diseases. 

Prognosis. The prognosis in cases of spinal syphilis is more favor- 
able than in the corresponding diseases of a non-specific character, but 
complete recovery is not often experienced, and relapses frequently 
occur, especially if the treatment is suspended at too early a period. 

Treatment. The treatment of spinal syphilis should be conducted 
in the same way as that for cerebral syphilis. Electricity, massage, 
and other expedients may also be employed, as in cases of a non- 
syphilitic character. 

Syphilis of the Peripheral Nerves. 

The peripheral nerves are not often directly affected by syphilitic 
disease, but they are frequently subjected to pressure, and to more or 
less complete consequent para lysis, through the development of gummata 
in their neighborhood, or by reason of an encroachment upon their trunks 
through syphilitic constriction of the bony canals through which many of 
them pass in their course from the brain and spinal cord to the out- 
lying portions of the body. Severe neuralgias sometimes occur during 
the early portion of the secondary stage of syphilis, apparently as a 
consequence of functional disturbances of the nerves through the irri- 
tating character of the infected blood and lymph by which they are 
nourished. 

Hereditary Syphilis — Syphilis Hereditaria. 

Etiology. Since syphilis is a constitutional disease, it is transmis- 
sible from parents to their children, but fortunately the line of heredi- 



HEREDITARY SYPHILIS. 213 

tary descent is here arrested, and the children's children escape. 
Syphilis may be transmitted by either parent, or by both of them, if 
both are diseased. It is during the secondary period that such heredi- 
tary transmission chiefly occurs. The children of parents who are 
suffering with tertiary symptoms rarely exhibit hereditary syphilis, but 
are weakly, scrofulous, and rickety. Such children often die of con- 
sumption, or of tubercular meningitis. 

When hereditary syphilis is derived from the father it sometimes 
happens that the mother remains uninfected, though her infant exhib- 
its all the signs of the hereditary disease. It is a remarkable fact that 
a mother who has thus escaped infection during pregnancy may never- 
theless be infected by nursing her infant, if an excoriation or fissure of 
the nipple permits the entrance of infected secretions from the child's 
mouth. Sometimes, however, a previously healthy mother, is infected 
by her offspring before its birth. 

It sometimes happens that the elder children of syphilitic parents 
inherit the disease, while the younger escape. This is due to the fact 
that with the progress of time the possibility of transmission gradually 
diminishes. Sometimes children are born alternately syphilitic and 
non-syphilitic. This is due to the fact that the disease is most infective 
and transmissible when actively manifested in the parents. During 
the period of latency children may be conceived without transmission 
of the infection. 

It sometimes happens that in a previously healthy family the mother 
becomes infected during her pregnancy. Under such circumstances 
the infant is also sometimes infected directly from the blood of the 
mother, but sometimes escapes completely, and is born and remains 
healthy. It has been attempted to show that such infection can only 
take place during the first five months of pregnancy, but it is probable 
that there is no uniform rule in such cases. The numerous accidents 
by which an infant, though healthy before birth, can be infected during 
delivery, or in the act of nursing, render it extremely difficult to 
decide when, where, or how the contagion may have entered its 
tissues. 

Symptoms and Diagnosis. The most common consequence of 
hereditary syphilis is abortion. The prematurely delivered foetus is 
usually in a state of maceration and decomposition. This result is due 
to thickening of the walls of the umbilical vessels, and the formation of 
thrombi in the vascular canals of the umbilical cord. Sometimes gummy 
tumors and interstitial proliferation of the connective tissue of the pla- 
centa produce such obstruction to the passage of the blood that death 
of the foetus necessarily results. The majority of abortions are thus 
explained, and it is an especially significant fact when miscarriages are 
often repeated. 

When, however, a living child is born, death frequently follows in a 
short time as a consequence of marasmus and slow starvation. The 
infant rapidly wastes away, and presents a miniature counterfeit of 
extreme old age, emaciation, and death from exhaustion. The bones 
and the internal organs exhibit after death the characteristic changes 
of syphilis. 



214 PARASITIC AN! INFECTIVE DISEASES. 

S met mes, however, the newborn child pi : first the ap 

anee of perfect health, but presently the symptoms of and 

5ti iction in the nasal pa* ges -pear. Am ent disci _ 

trickles from the nostrils ; breathing is rendered difficult, and nu 
is almost impossible, since the child cannot respire through the 

: of suction. Condylomata frequently make their appear- 
ance in the corners of the mouth, and roseolar or papular eruptions 
become visible upon the surface of the body. The papular for: 

- - me the eh i ;teristics of the condyloma, and are developed 
in the same -lalities that re rincipally affected in cases of ordinary. 
secondary syphilis. Bullous and pustulous syphilides are also fre- 
.- encountered. Pemphigus is not uncommon upon the palms of 
the hai L soles of the feet : and in the mouth and throat various 

Lesions :: :-.:: t ~:iieruatous. roseolar. and condyle _ : is character are 
manifested. A peculiar notching of the teeth has been described by 
Hotel rristic of heir ry syphilis Fig 82 . but it is 

Fig. -2. 




_ed teeth. If _ \:ion of permanent teeth fonnd in hereditary syphilis. 

(Mr. Josathax Hr: - - 

certain that this conformation also occurs in ses here there can be 
no question of syphilis. The roots of the nails are sometimes inv 

aronvchial inflammation, and in many sases the epiphyses of the 
bones are painful. Iritis is usually one of the later manifestati-: is : 
hereditary syphilis. 

Hereditary syphilis sometimes completes its with the manifes- 

tation of the lesions of the secon ry si ge; but in m . riary 

sympt taring :he period of second dentition or at the 

ige : iberty. The local lea symptoms that are produced in 

the different org as ::' the body by tertiary syphilis all find their 
terpart in the later manifestations of hereditary syphilis. In many 

ses the lisease can be differentiated from tuberculosis only by the 
ice of tube ■ L 11 i in the sec :ions. and by non-reactioi. 

-rculin. 

Hereditary syphilis sometim :he uns ise of 

re unusual among children — e. In many - 3 

there is gradual failure of the health, emaciation, and loss 
with-' for such disorder- leath may be thus 

produ - snee of progress : austion. 

The fiv- of hereditary syphilis are usually uianiiV 

after the third week from the birth of the child. If the health remains 
intact for six months, it is bable that the die - ... 

quently appear. Cases in which hereditary syphilis is s first 

apparent at the age of puberty or later. ses of tubercu- 



HEREDITARY SYPHILIS. 215 

losis, or patients in whom the early stage of hereditary syphilis was 
overlooked during infancy. 

Pathological Anatomy. Among the most important changes 
that are caused by hereditary syphilis is a disease of the epiphyses of 
the long bones and the cartilaginous extremities of the ribs. The 
tissues between the shaft of the bone and the epiphysis undergo an 
irregular proliferation and softening, which sometimes produces a sepa- 
ration of the epiphysis from its shaft. This disorder may be frequently 
recognized by an audible crepitation when pressure is made with the 
finger over the site of the morbid process. When the bones of the ex- 
tremities are thus affected their movement is attended with pain and 
difficulty, so that the appearance of paralysis is closely counterfeited. 
In the serous cavities of syphilitic children who were born dead, serous 
effusions are often discovered, and the serous membranes exhibit every 
variety of thickening, contraction, and adhesion. The internal viscera 
exhibit all the changes that have been previously described as a conse- 
quence of tertiary syphilis. 

Prognosis. The prognosis in hereditary syphilis is always of a 
most serious character. Death frequently occurs as a direct conse- 
quence of the disease, and if life be prolonged, it is often rendered 
miserable by manifold diseases involving any or all of the organs of the 
body. 

Treatment. In order to prevent the transmission of syphilis as an 
hereditary disease, marriage should not take place within three years 
after an original infection, and then only after at least six months of 
complete recovery have been experienced. The renewal of any symp- 
toms of the disease on the part of either parent should be followed at 
once by an active course of treatment. If a healthy mother should 
give birth to a syphilitic infant, she should be warned of the danger 
that attends the act of suckling her child, and every precaution should 
be taken to prevent erosion of the nipple, through which infection might 
take place. She should also take iodide of potassium in five-grain 
doses, three times a day, partly as a possible prophylactic, and partly 
for the purpose of medicating the milk with which the child is nour- 
ished. If a wet-nurse be provided for the infant, similar precautions 
should be observed. If a syphilitic mother should give birth to a 
healthy child, under no circumstances should she be allowed to nurse 
the infant, since it might be easily infected, if condylomata or bleeding 
fissures exist about the nipple. The occurrence of maternal syphilis 
during pregnancy should be the signal for active inunction with mercu- 
rial ointment. 

To an infant in whom are apparent the symptoms of hereditary 
syphilis should be given three times a day the tenth of a grain of calo- 
mel, rubbed up with a grain of sugar of milk. The mouth should be 
washed after each period of nursing with a 2 per cent, solution of chlo- 
rate of potassium. Some physicians prescribe daily baths containing 
corrosive sublimate, but if these are employed great care should be 
taken to avoid the entrance of the bath water into the eyes or mouth 
of the infant. A wooden tub should be used, since the mercurial solu- 
tion would be likely to attack a metallic container. Exuberant papules 



216 PARASITIC AND INFECTIVE .DISEASES. 

upon the surface of the skin may be successfully repressed by sprinkling 
them with calomel powder. Tertiary lesions should be treated with 
iodide of potassium. External ulcerations are to be dressed with 
mercurial plasters ; and lesions of the mucous membrane should be 
frequently touched with iodized glycerin. 



CHAPTER XIV. 

EPIDEMIC CEREBROSPINAL MENINGITIS. 

This disease is an acute, epidemic, infective inflammation of the 
meninges of the brain and spinal cord. 

Symptoms and Course oe the Disease. Cerebrospinal menin- 
gitis is ushered in abruptly by severe chills and headache, often accom- 
panied by vomiting. The temperature rises to 101° or 102 C F. : the 
fever is irregular, often intermittent or remittent. The patient is fre- 
quently delirious, there is rigidity of the spinal column, the head is 
retracted, the limbs are stiffened and drawn up toward the body : with 
young children there may be convulsions. The patient is greatly 
agitated, striving to get out of bed. crying and shouting. All the 
symptoms are aggravated at night. This is the congestive stage of the 
disease, consequent upon the commencement of inflammation. The 
existence of nervous irritation, after the expiration of from one to 
three days, manifests itself by an eruption of sudamina or of herpetic 
vesicles about the mouth. The expression of the countenance indicates 
pain, the face is pale, the eyes are red. the skin is dry and roughened 
by the spasmodic condition of the cutaneous muscular fibres. Petechial 
spots and various roseolous eruptions make their appearance, the pupils 
of the eyes are contracted, sometimes there is strabismus. 

As the process of meningeal effusion advances, the symptoms of 
cerebral compression and depression appear. The patient becomes dull 
and stupid, no longer giving audible utterance to his sufferings ; the 
countenance becomes dull and expressive of stupor, sensibility dimin- 
ishes, the pulse becomes less frequent, and the respirations increase in 
number. The bowels are constipated, and there is retention of urine. 
As the disease advances stupor merges into coma, the pupils dilate, the 
ocular muscles become paralyzed, the limbs are agitated by spasmodic 
movements, which finally terminate in the quiescence of paralysis. 
The pulse becomes more and more frequent, compressible, weak, and 
irregular, though the heart may continue to palpitate violently. The 
respiratory movements do not correspond with the cardiac pulsations : 
they become irregular, less frequent, sometimes before death manifest- 
ing the phenomena of Cheyne-Stokes respiration. Cold perspiration 
appears upon the pale and livid skin, and death occurs in a condition 
of complete coma and exhaustion, sometimes preceded or terminated 






EPIDEMIC CEREBRO-SPINAL MENINGITIS. 217 

by violent convulsions. Death may occur during the course of the 
first day, but the fatal termination is generally reached before the ex- 
piration of a week from the commencement of the attack. When not 
thus early fatal, the average duration of the disease is from twenty-five 
to thirty days. 

A tendency to recovery is indicated by the cessation of convulsions, 
subsidence of excitement, return of natural sleep, recovery of con- 
sciousness, and the disappearance of fever. Convalescence is usually 
slow, and may be imperfect. Permanent loss of certain nervous func- 
tions is not uncommon as a consequence of the injuries inflicted upon 
the brain and spinal cord by the inflammatory process. 

Varieties. Cerebro-spinal meningitis may be characterized by the 
predominance of certain symptoms in particular cases. 

1. During the course of the epidemic the disease sometimes com- 
mences with the ordinary symptoms of irregular fever, headache, vom- 
iting, stiffness of the neck, nervous excitement, and delirium ; but after 
a day or two the symptoms subside with a critical perspiration, and 
convalescence is commenced. 

2. Apoplectiform cerebro-spinal meningitis is characterized by sudden 
invasion, speedy loss of consciousness, violent chills, intense headache, 
rapid development of all the most active symptoms of the disease, and 
death within a few hours after the commencement of the attack. 

8. In certain cases the characteristic phenomena are of spinal origin. 
The patient does not become delirious, nor is he comatose, but there is 
intense pain in the back and limbs, with muscular rigidity and con- 
traction. A lingering death is preceded by exhaustion, wakefulness, 
and intense suffering. 

4. In the cerebral form of the disease the prominent symptoms are 
those of cerebral excitement that continues from twelve to twenty-four 
hours, and is followed by evidences of effusion and compression of the 
brain, terminating in death. The spinal symptoms are few and insig- 
nificant. 

Complications. The organs of special sense, the eye and the ear, 
are sometimes disorganized by the extension of inflammation to the 
internal structures of the eye and of the inner ear. The sense of 
smell is occasionally in like manner destroyed. The third, fourth, 
sixth, and seventh nerves sometimes become paralyzed as a consequence 
either of pressure upon their trunks, or of degeneration involving the 
nerve roots. Outside of the skull the serous membranes of the body 
not unfrequently become involved. Pneumonia is a common complica- 
tion. The liver and the kidneys are also sometimes affected. 

Pathological Anatomy. The characteristic changes that are pro- 
duced by epidemic cerebro-spinal meningitis, are inflammation of the 
pia mater and a sero-purulent exudation upon the meninges of the 
brain and spinal cord. Even in cases of speedy death, microscopical 
examination indicates the presence of leucocytes along the vessels of 
the brain. The lymphatic sheaths of the small vessels are filled with 
lymph-cells and red blood-corpuscles, while an exudation of small 
round cells may be discovered in the cortex of the brain. The cerebral 
ventricles are distended with liquid. There is an evident tendency to 



213 PARASITIC AND INFECTIVE DISEASES. 

encephalitis or to myelitis with abscess formation. When life has been 
prolonged to the usual limit of the disease, the cerebral veins and 
sinuses are distended with dark blood ; the vessels of the pia mater are 
bordered by the products of exudation : the meshes of the network are 
occupied by a gelatinous liquid that contains fibrin and is composed of 
serum. The longer the duration of the disease the greater the turbidity 
of the exudation by reason of increase in the leucocytes and pus cor- 
puscles that float in the serous liquid. A similar exudation fills the 
ventricles of the brain. In cases of considerable duration the liquid 
becomes distinctly sero-purulent. and sometimes also contains red 
blood-corpuscles. 

The arachnoid membrane exhibits little change, though it sometimes 
is covered by a layer of pus that has been poured out upon it. The 
superficial layer of the cortex of the brain is often cedematous and 
softened. 

Similar evidences of vascular engorgement and sero-purulent exuda- 
tion into the cavity of the arachnoid are presented by the membranes 
of the spinal cord. The products of exudation are more abundant 
upon the posterior surface of the cord than upon the anterior, and they 
increase in quantity as the lower extremity of the cord is approached. 
The cauda equina is often enveloped in a thick layer of pus The 
cavities of the inner ear are sometimes filled with pus. The structures 
of the eye may be found inflamed, with pus in the anterior and pos- 
terior chambers of the organ. The iris, the cornea, and the conjunc- 
tiva may all be disorganized by the inflammatory process. The heart 
is sometimes softened : the pericardium may be distended by serous or 
sero-purulent exudation. Endocarditis is sometimes observed. The 
bronchi often exhibit evidences of inflammation, and pneumonia may 
also exist. The pleural cavity sometimes contains a more or less puru- 
lent exudation. The abdominal organs are rarely affected, though the 
kidneys may contain bacteria in the glomeruli, where they have caused 
degeneration and hemorrhage. 

Etiology. In the exudations of cerebro-spinal meningitis are found 
a number of different bacteria which may be cultivated outside of the 
body, and which are fatal to rabbits. Micrococcus pyogenes aureus. 
staphylococcus aureus, streptococcus pyogenes, the pneumococcus, and 
other bacteria are numerous in the products of inflammation. The 
micrococcus of pneumonia appears to be the most common and efficient 
cause of special inflammation of the meninges : but it is probable that 
the presence of other bacterial forms gives character and variety to the 
clinical symptoms that mark the different forms of the disease. 

The epidemic character that is exhibited by cerebro-spinal meningitis 
is exhibited in its frequent association with epidemics of influenza, 
scarlet fever, measles, mumps, and other eruptive fevers. Sometimes, 
however, such epidemic association has not been apparent. It is a 
disease that prevails epidemically during cold weather and in cold 
climates. It occurs chiefly among those members of the community 
who are compelled to live under unfavorable hygienic conditions. It 
attacks young children and young people by preference to those of 
more advanced age. It has been frequently observed among soldiers 



EPIDEMIC CEREBRO-SPINAL MENINGITIS. 219 

and prisoners, among the pupils of boarding-schools, and among the 
tenants of other overcrowded and ill-ventilated habitations. 

But the real cause of the prevalence of the disease lies in the activity 
of a communicable virus, which is transmissible and may be. diffused 
under favorable circumstances, very much as the contagia of mumps 
and pneumonia are propagated. 

Diagnosis. The slight or abortive forms of the disease may some- 
times fail of recognition, unless the acknowledged existence of an 
epidemic has quickened the perceptions of the attendant. Fully de- 
veloped forms of the disease can be distinguished from typhoid fever 
by the irregular temperature, and by the frequent respiration that 
characterizes the meningeal disease. Scarlatina exhibits an elevation 
of temperature that is not observed in meningitis. From tubercular 
meningitis the disease may be distinguished by the violence of its 
symptoms and its rapid course, and by the absence of tubercular pre- 
disposition on the part of the patient. From simple meningitis a dis- 
tinction may be very difficult, but epidemic tendencies and the extension 
of the symptoms over all parts of the cerebro-spinal axis, should 
determine the diagnosis of epidemic cerebro spinal meningitis. 

Prognosis. The mortality from cerebro-spinal meningitis varies 
in different localities and in different epidemics. It may fall as low as 
30 per cent, or it may ascend as high as 90 per cent. Among the 
symptoms of danger may be mentioned a weak, slow, and irregular 
pulse, rapid respiration, excessive dryness of the skin, great elevation 
of the temperature, and coldness of the extremities. Favorable symp- 
toms are general warmth of the skin, perspiration, bright color upon 
the face, moderate rate of respiration, fulness and steadiness of the 
pulse. Delirium and somnolence are alarming symptoms. Coma, 
associated with depression of the rate of respiration, is a fatal symptom. 
Even after the establishment of convalescence recovery may be imper- 
fect, entailing life-long misery or an early death. 

Treatment. Few diseases are more intractable. In cases that are 
marked by violent headache and active determination of blood to the 
head, leeches may be applied behind the ears and cups to the spine. 
Cold compresses may be laid upon the head, but the application of ice 
is generally very disagreeable and increases the headache. Emetics 
and purgatives are useless. Ice and small doses of resorcin may be 
given for the relief of nausea and vomiting. Scrupulous cleanliness 
must be observed in order to prevent bedsores. The diet must consist 
of liquids administered by rectal injection, if the patient cannot swallow, 
or if the stomach is intolerant of everything. Alcoholic stimulants 
and external heat are useful in cases of prostration with coldness of 
the extremities. Mercury, iodide of potassium, and quinine are useless 
during the acute stages of the disease. The hypodermic use of mor- 
phine and atropine affords the greatest relief, and is followed by the 
largest number of recoveries. Chloral, bromide of potassium, and 
belladonna are recommended, but their utility is very doubtful in 
comparison with that of the opiates. 



220 PAKASITIC AND INFECTIVE DISEASES. 



CHAPTER XV. 

ERYSIPELAS. 

Eeysipelas is an acute, infective disease characterized by active 
febrile movement, by an inflammatory eruption of variable intensity, 
involving the skin and subcutaneous areolar tissues, followed by desqua- 
mation and recovery, or by a fatal result that is dependent upon com- 
plications and the development of a typhoid condition. 

The older authors have sought to establish a distinction between sur- 
gical erysipelas that occurs in connection with wounds or ulcerating 
surfaces, and a form of the disease that is chiefly manifested upon the 
cutaneous surface of the body, often without any obvious traumatism 
as an exciting cause ; but this distinction can be no longer maintained. 
It is now believed that erysipelas is a unit so far as its nature and 
specific contagion are concerned. In the vast majority of cases the 
contagion finds entrance into the body through some solution of con- 
tinuity involving either the external or the internal surfaces of the body. 
The symptoms that follow inoculation with the infective agent are 
varied in accordance with the locality that is affected, and with the 
predisposing conditions that influence the general condition of the 
patient. It is, moreover, highly probable that the contagion itself may 
exhibit different degrees of virulence produced by various conditions of 
growth and propagation. With the manifestations of the disease as it 
complicates wounds and the operations of surgery, the physician has 
nothing to do. For him the affection is only interesting as it involves 
the surface of the body or those organs that lie within the province 
of medicine. 

Symptoms. The course of the disease may be divided into three 
periods : 1. The stage of incubation. 2. The stage of invasion and 
eruption. 3. The stage of decline. 

Incubation. The duration of this period varies from twelve hours to 
two weeks. During this time there may be a slight disorder of the 
general health, but ordinarily no characteristic symptoms precede the 
chill that ushers in the stage of invasion and eruption. The chill is 
usually long and severe, and is followed by a rapid elevation of tem- 
perature, which may in a few minutes rise to 104° or 105° F. The 
pulse is frequent, full, and strong ; the tongue becomes covered with a 
thick, yellow fur, and there is severe headache, with pain in the back 
and limbs. From ten to twenty-four hours after the commencement of 
the chill, the seat of the future eruption becomes painful, and the 
lymphatic vessels and glands of the part are reddened and tender on 
pressure. In some cases this affection of the lymphatic system is less 
conspicuous than the simple cutaneous inflammation. 

Eruption. The possibly unnoticed wound which has been the point 
of entrance for the infective agent now becomes the starting-point of 



ERYSIPELAS. 221 

the eruptive process. The eruption is at first of a rose color, becoming 
gradually of a darker hue, and spreading in every direction upon the 
surface of the body. The fever continues with a severity in proportion 
to the intensity and amount of eruption. The temperature continues 
at about 104° F., rising a little at night, and falling a little in the 
morning. In severe cases the fever is continuous. In milder cases it 
may be either remittent or even intermittent. The course of the fever 
and its severity depend upon the progress of the disease and upon the 
extent of the complications that may arise. In mild cases the nervous 
system presents only the ordinary reactions of moderate fever ; but if 
the infective process be extensive and virulent, there may be delirium 
or even convulsions, especially among children. Nausea, vomiting, 
diarrhoea, and bleeding from the nose are sometimes observed. 

The eruption continues to extend by the enlargement of the circle 
that has the point of departure for its centre. As it advances, the por- 
tion of the skin that is recently invaded assumes a deep-red tint, while 
the part first attacked loses the intensity of its first eruptive color. The 
initial brilliancy of the eruption, at any given point upon the surface of 
the body, continues from two to five days, and then begins to subside, 
so that the advancing zone of active eruption leaves behind it a terri- 
tory in which every stage of the receding eruption may be observed. 
The eruptive process extends like fire in the grass of a prairie, that 
burns as it goes, and leaves behind it a region of desolation upon which 
vegetation will reappear in the order of its destruction. Upon the 
white skin the line of demarkation between the eruption and the unin- 
vaded portion is clearly defined ; but upon portions of the body where 
the skin is naturally dark, as upon the scrotum, and in patients with a 
dark complexion, the line is not so well marked. The site of the erup- 
tion may, however, be easily recognized by the roughness and swelling 
of the skin, and by the vesicles and bullae which are formed in the 
epidermis. Sometimes the cutaneous swelling is very considerable. 
This is most conspicuous where the areolar tissue is loose and abun- 
dant. For this reason, when the face is the seat of the disease, the 
eyelids swell to such a degree that the eyes cannot be opened. The 
nostrils become in like manner obstructed ; the mouth can scarcely be 
opened ; the cheeks are enormously enlarged, so that the original linea- 
ments of the countenance can be no longer recognized ; the ears look 
as if they had been thoroughly frozen and thawed. Even greater 
tumefaction and deformity accompany the development of the disease 
when it attacks the external sexual organs. 

The eruption does not always progress in a continuous zone, but may 
exist in separate and distinct patches. The course of the disease is 
sometimes interrupted by apparent subsidence, followed by renewed 
activity. The period of eruption may thus be prolonged for several 
weeks, until in certain cases the entire surface of the body has been 
involved. This form of the disease is called migratory erysipelas. 

Erysipelas generally terminates in recovery, but in certain cases, 
instead of a gradual decline of the eruption and fever, there is an 
increase in the intensity of the disease. The pulse becomes rapid and 
febrile; respiration grows more frequent; pulmonary complications 



222 PARASITIC AXD INFECTIVE DISEASES. 

may appear ; there is vomiting and diarrhoea ; the tongue becomes dry 
and brown ; there is constant delirium and nervous prostration, and 
the patient passes into the coma that terminates a typhoid condition. 
This unfavorable course of the disease is generally precipitated by 
previous alcoholic excess, and by a cachectic condition of the system. 

Decline. The temperature falls rapidly to the normal point, and the 
pulse follows suit. The tongue becomes clean, thirst diminishes, appe- 
tite returns, natural sleep occurs, the swelling of the skin subsides, red- 
ness gradually diminishes, the vesicles and bullae, which distended the 
epidermis, dry up and exfoliate. Sometimes the desquamation is very 
trifling and furmraceous in character ; in other cases the epidermis 
peels off in considerable flakes, leaving the new skin red and tender for 
a considerable time. As the brilliant color fades, it is succeeded by a 
yellowish or bluish tint, which continues for several weeks. The hair 
sometimes falls off, but is soon succeeded by a new growth. In those 
portions of the body where the skin is loose and thin, diffuse infiltra- 
tion of the areolar tissue sometimes continues for a considerable period, 
and may furnish a predisposing cause for renewed invasions of the dis- 
ease. During convalescence the urine frequently contains a small quan- 
tity of albumin and epithelial casts from the kidneys. 

In scorbutic and cachectic subjects subcutaneous hemorrhages some- 
times accompany the eruption of erysipelas. The surgical varieties of 
erysipelas involve the deep tissues of the body, and frequently occasion 
extensive suppuration and gangrene of the parts that are involved. 
These forms of the disease are fully treated in surgical text-books. 

The inflammatory swelling of erysipelas is not limited to a cutaneous 
surface alone. When the eruption appears upon the face it is not an 
uncommon event to find the nasal passages also invaded. The fauces, 
pharynx, larynx, and trachea may also be involved. (Edema glottidis 
may be produced by the resulting inflammation about the orifice of the 
larynx. Erysipelatous pneumonia may occur as a consequence of the 
extension of the disease from without, or as a consequence of invasion 
of the pulmonary circulation by infectious emboli. Under these cir- 
cumstances the lungs become rapidly involved throughout their entire 
extent, and death soon follows. The alimentary canal may also be 
attacked by erysipelas, frequently extending into the mouth and pharynx 
from the face. It sometimes originates within those cavities, involving 
the tonsils, and extending to the submaxillary and cervical lymphatic 
glands. It may result in abscess or gangrene of the fauces and pharyn- 
geal walls. The oesophagus escapes the ravages of the disease. A few 
cases have been recorded in which the disease has extended into the 
intestinal canal. The urethra and the bladder have been occasionally 
attacked, both in males and in females, and the extension of the disease 
throughout the whole course of the uterine passages is a not infrequent 
event. This, however, is a different thing from the puerperal inflam- 
mations that are produced by erysipelatous infection after delivery. 
Erysipelas communicated to a female patient at that time may cause one 
of the forms of puerperal fever ; and, vice versa, the septic discharges 
of puerperal fever may cause erysipelatous inflammation if conveyed to 
a wound upon the person of a previously uninfected patient. The 



ERYSIPELAS. 223 

close relation between erysipelas and puerperal fever has been thus 
many times demonstrated. 

Pathological Anatomy. Examination of the skin during the 
period of inflammation shows the margin of the eruption occupied by 
distended capillaries forming a zone of congestion. The process of 
exudation is more conspicuous as the central portions of the inflamma- 
tion are approached. At first the bloodvessels are surrounded with leu- 
cocytes, which later become infiltrated throughout the areolar tissue of 
the skin. As the inflammation progresses, the cutaneous and sub- 
cutaneous tissues become swelled and infiltrated with serous and cor- 
puscular exudates. The lymphatic vessels often share in the inflamma- 
tory process, which then follows the lymphatic canals in advance of 
the zone of congestion, producing a species of fringe-like process that 
pushes out into the healthy tissues, and may be felt by the ringer in 
advance of the ridge-like border that marks the margin of the inflamed 
zone or patch. The lymphatic glands also share in the swelling that 
follows the invasive process. 

Occupying the tissues along the margin of the advancing inflamma- 
tion are numerous micrococci. These are streptococci, and they occur 
in pairs or in chains. They occupy the intervascular spaces, the 
lymphatic vessels and glands, and the fat cells of the adipose tissue. 
They appear to be identical with the forms of streptococcus pyogenes, 
and must be regarded as the cause of the disease. They are most 
numerous in the advancing border of the inflammation, and disappear 
from the tissues as the inflammatory swelling subsides. 

In addition to the evidence of disease already mentioned in connec- 
tion with the respiratory organs and the alimentary canal, endocarditis, 
pericarditis, and inflammation of the walls of the bloodvessels are 
sometimes observed. The liver is enlarged and dark in color; the 
spleen is also softened and sometimes enlarged ; the pancreas remains 
healthy ; the kidneys are frequently inflamed and reveal the presence 
of bacteria identical with those discovered in the skin. The serous 
membranes of the body, the peritoneum and the pleural membranes, 
are occasionally inflamed, and the serous cavities of the joints are 
sometimes the seat of an inflammatory process which may be consid- 
ered, when purulent in character, as a manifestation of general septi- 
caemia. 

Diagnosis. Simple erysipelas is not difficult of recognition, unless 
it occupy the scalp or the internal cavities of the body, or portions of 
the skin that are deeply pigmented. 

From inflammatory rheumatism it must be distinguished by the facts 
that rheumatism occupies the articulations ; that the redness is re- 
stricted to the region of the joints, and is not as highly colored as in 
erysipelas. 

Erysipelas may be confounded% T ith certain cutaneous diseases, such 
as the various forms of erythema, which may be distinguished by the 
lower grade of fever ; by the darker color of the eruption ; by the local 
circumscription of the patches, and by their absence from the face. 
Eczema may be distinguished by the character of the eruption, which 



224 PARASITIC AND INFECTIVE DISEASES. 

is minutely vesicular, unattended by fever, and productive of much 
itching. 

Urticaria may be distinguished by the transient character of the 
eruption ; by the intense itching ; and by the limited character of the 
tumefaction of the wheals and patches that form the eruption. 

The various eruptive fevers may be distinguished from erysipelas by 
the history of the case, and by the characteristic eruptions as they 
appear. The phlyctenoid forms of erysipelas may sometimes be mis- 
taken for herp>es or pemphigus, but in herpes the eruption follows the 
course of the nerves ; there is less fever, and neuralgic pain is intense. 

Prognosis. Mild, uncomplicated erysipelas is not often fatal. The 
gravity of the disease depends upon the condition and diathetic predis- 
position of the patieDt, and upon the epidemic influence that forms the 
environment. The disease is especially fatal among the intemperate, 
and at the extremes of life, particularly when complicated by chronic 
diseases of the heart, liver, and kidneys. The mortality varies from 
1 to 50 per cent. 

It is an interesting fact that certain diseases are sometimes benefited, 
if not cured, by the intercurrence of erysipelas. Insanity, rheumatism, 
asthma, neuralgia, dropsies of renal and cardiac origin, and various 
surgical diseases, are said to have been cured by an attack of erysipelas : 
but when the disease occurs as a secondary event, during the period of 
decline of other infective diseases, the effect upon the health is very 
unfavorable. 

Etiology. It has been admitted that the contagion of erysipelas 
{streptococcus) must be introduced into the lymphatic circulation before 
it can become active in the body, and that it can only find access to 
the circulating fluids through some lesion of the skin or of the mucous 
membranes of the body. For this reason the disease usually occurs 
among wounded patients and the subjects of surgical operation. A 
minute scratch, vesicle, or pustule may afford entrance to the poison. 
The solution of continuity through which it finds entrance to the body 
may completely heal during the period of incubation ; as may be some- 
times witnessed after abortive attempts at vaccination, when erysipelas 
attacks the adjacent skin a few hours or days after the incisions have 
healed, and the insignificant scab has fallen. 

Like other infective diseases, the occurrence of erysipelas is favored 
by cold, damp weather, and by unfavorable hygienic conditions of life. 
For this reason it is frequently associated with the prevalence of other 
epidemic diseases, especially among the inhabitants of new countries 
and overcrowded cities. Among individual predisposing causes may 
be reckoned the influence of age, sex, and period of life. It is very 
common among cachectic infants and among aged people. It is more 
frequent among men than among women. In short, its occurrence is 
proportioned to the frequency of traumatism or cutaneous lesions of 
any sort among the different members of the community. 

Treatment. The indications for treatment are: 1. To secure 
favorable hygienic surroundings : 2. To make such local applications 
as shall serve to retard the progress of inflammation, and add to the 



ERYSIPELAS. 225 

comfort of the patient ; 3. To administer such remedies as shall reduce 
fever, promote elimination, and prevent exhaustion. 

Perfect ventilation of the apartment occupied by the patient must be 
secured. The diet must be liquid and agreeable. If the stomach 
rejects food, and the patient loathes everything, it is unnecessary to 
force nourishment upon him. Iced drinks and the sucking of ice often 
give more relief than anything else. If, however, the typhoid con- 
dition appear, it will be found necessary to give milk, egg-nog, and 
alcoholic stimulants as freely as possible. During the period of conva- 
lescence the diet should be gradually varied until the full allowance is 
reached. 

The local treatment of erysipelas may be restricted to the use of 
emollient applications that exclude the air from the skin, such as vase- 
line, simple cerate, starch powder, lycopodium, oxide of zinc, or the 
subnitrate of bismuth. Resin cerate is valuable as a stimulant to the 
capillary circulation at the seat of eruption. Tincture of iodine and 
nitrate of silver have been recommended as local applications for the 
purpose of aborting the eruption ; but frequent trials have demonstrated 
their inutility. Elastic collodion forms an excellent application when 
the region of eruption is not too extensive. Hypodermic injections 
of carbolic acid and other antiseptic substances have been practised with 
a view to the destruction of the bacteria that multiply in the skin along 
the margin of the advancing eruption ; but the utility of this mode of 
treatment is exceedingly questionable, and it has been generally aban- 
doned. Great relief is often obtained by spraying the face two or three 
times a day with the following solution : 

li .— Hydrarg. bichlorid. "> „ o . r 

Acid, tartaric. J .... g 

Alcohol 3jss. 

Ether, sulphuric. ....... ^xvj. — M. 

The eyes should be covered with borated cotton during the oper- 
ation. 

Punctures and scarifications of the skin are employed, chiefly in 
surgical erysipelas. The various antiseptic lotions that have been 
praised owe their principal efficacy to the cooling effect of their evapo- 
ration. 

Since there is no safe antidote to the poison that produces the dis- 
ease, very little advantage results from the administration of the 
numerous antiseptic remedies that have been recommended in the treat- 
ment of erysipelas. So far as they reduce the symptomatic fever and 
add to the comfort of the patient, they are useful ; but beyond those 
limits nothing will be gained by activity in their exhibition. Antipy- 
rine, acetanilide, and phenacetine may be administered for their febri- 
fuge effects. Pain may be relieved by the use of opiates. Nausea and 
vomiting will often be controlled by the use of dilute hydrocyanic acid 
and the subnitrate of bismuth. Nervous exhaustion and a typhoid 
condition call for the administration of alcohol, strychnine, and tonic 
doses of quinine and iron, such as are furnished in the well-known 
elixir of iron, quinine and strychnine. Tincture of the perchloride of 

15 



226 PARASITIC AND INFECTIVE DISEASES. 

iron has been extensively employed in the treatment of the disease, but 
its beneficial effects are of the rarest occurrence, and are in no way 
superior to the results afforded by more agreeable preparations of iron, 
or by dilute mineral acids. During the period of convalescence much 
benefit will be obtained from the administration of tonic and restora- 
tive drugs, associated with good diet and gentle exercise in the open 
air. Recently inflamed portions of the skin should be protected for 
some time from the direct rays of the sun and from strong winds when 
exposed out of doors. 



CHAPTEE XVI. 

MUMPS— PAROTITIS. 

An acute, epidemic, contagious inflammation of the salivary glands. 

Symptoms. The invasion of the disease is attended by the symptoms 
of moderate fever. In addition to the ordinary headache that accom- 
panies febrile conditions, there is complaint of pain and stiffness about 
the articulations of the lower jaw. High fever and nervous symptoms, 
such as convulsions, are rare. The tongue is coated, and the symptoms 
of catarrhal stomatitis may be observed within the oral cavity. Some- 
times there is vomiting or diarrhoea. After a few days, a swelling in 
the region of the parotid gland becomes manifest, ordinarily upon the 
left side. This speedily occupies the space behind the angle of the jaw, 
displacing the ear upward and outward. The submaxillary and sub- 
lingual glands soon participate in the enlargement, and in the majority 
of cases the glands of the other side become involved. Movements of 
the jaw, and the effort of swallowing, become exceedingly painful. 
The head is held stiffly erect, or may be drawn backward, or toward the 
unaffected side if but one gland be affected. In severe cases the mucous 
membrane of the pharynx and larynx may swell to an extent that 
interferes with vocal utterance and respiration. The temperature rarely 
exceeds 102° F., subsiding as the swelling progresses, and ascending 
moderately with the invasion of the gland upon the opposite side. 

The duration of the disease is quite variable. The period of incu- 
bation occupies one or two weeks ; the swelling of the glands may 
occupy another week or more ; and, if both sides become involved, the 
disease may continue for three or four weeks. 

Occasionally the disease affects the genital glands. In the male sex 
orchitis may occur ; with female patients some inflammation may occur 
in the mammary glands, in the ovaries, or in the glands about the 
vulva. These inflammations, generally subside after a few days without 
unfavorable results, though partial atrophy of the affected glands is 
sometimes observed. 

Diagnosis. During the early period of invasion it may be impos- 
sible to distinguish the fever of mumps from that by which other infec- 






SECONDARY OR SYMPTOMATIC PAROTITIS. 227 

tive processes are introduced ; but with the appearance of swelling in 
the parotid region, diagnosis becomes greatly simplified. From tumors 
involving the submaxillary region, it may be distinguished by the febrile 
movement and the rapid development of the growth. Tubercular 
glands in the neck occupy the sides of the neck and the submaxillary 
region. The tumors of lymphadenoma are developed without fever, 
and their growth is more gradual than is the case with the parotid 
enlargement in mumps. 

Etiology. The disease is propagated by a contagion, of which the 
nature has not been positively decided, though its bacterial origin can 
hardly be doubted. It is communicated by contact rather than through 
the atmosphere ; consequently its diffusion is not rapid nor as universal 
as that of measles or scarlet fever. 

Pathological Anatomy. The swelling of the salivary glands 
results from the action of the contagion, which, probably, reaches the 
tissues through the mouth and the salivary ducts. This excites an 
inflammatory exudation into the connective tissue of the glands. This 
usually disappears by resolution, but in rare cases may progress to sup- 
puration or gangrene. 

Prognosis. Recovery is almost universally the result. The rare 
occurrence of death must be referred to complications of the disease. 
Of these, one of the most dangerous is meningitis. 

Treatment. Active medication is quite unnecessary. Fever may 
be relieved by the use of antipyrine ; and pain in the region of the 
parotid may be allayed by the use of opiates in small and frequent 
doses. The mouth and fauces should be frequently disinfected with a 
solution of chlorate of potassium, of boric acid, or Listerine, or the 
permanganate of potassium. If agreeable to the patient, the face and 
neck may be anointed with vaseline, or with liniment containing bella- 
donna and aconite ; and the swollen glands may be covered with warm 
flannel or with cotton-wool. The patient should be kept in bed, and 
the food should be of a liquid character. Orchitis may be treated by 
supporting the inflamed gland in such a way as to prevent traction upon 
the spermatic cord. Local applications of a warm and anodyne char- 
acter may be employed as in the treatment of the enlarged parotid 
gland itself. 



CHAPTEE XVII. 

SECONDARY OR SYMPTOMATIC PAROTITIS. 

This is an inflammation of the parotid gland that occurs as a com- 
plication of various infective diseases, such as pyaemia, the plague, 
typhus, typhoid, relapsing and scarlet fevers, measles, dysentery, and 
cholera. It is caused by a special infection of the parotid gland with a 
poison, probably the pyogenic cocci, that is propagated in the system 
during the course of the primary disease. It usually affects but one of 



228 PARASITIC AND INFECTIVE DISEASES. 

the parotid glands, and at a late period in the course of the primary 
disease, or even after the cornineneeinent of convalescence. If the 
glandular swelling commence before the conclusion of the primary fever, 
the local changes alone attract attention. If the inflammatory process 
has been deferred until the period of convalescence, a renewed febrile 
movement may mark the commencement of the inflammation. The 
gland swells exactly as in epidemic mumps : but it soon becomes evident 
that the inflammatory process is not restricted to a simple serous exuda- 
tion involving the connective tissue. 

The tumor becomes tense, shining, hot, reddened, and painful The 
formation of abscess is indicated by fluctuation followed by rupture of 
the skin and the discharge of pus. In some cases the substance of the 
gland becomes gangrenous. The process of suppuration sometimes 
extends into the neck, or may burrow among the muscles about the 
angle of the jaw. with rupture of the abscess into the mouth, the 
pharynx, the ear. or even into the anterior mediastinum. The bones 
at the base of the skull are sometimes involved in the destructive 
process. Thrombi may form in the jugular veins and in the sinuses of 
the brain. Such cases are almost inevitably fatal. 

The treatment of secondary parotitis must be conducted in accordance 
with the requirements of antiseptic surgery. An early outlet should 
be secured for imprisoned pus, and the cavity of the abscess must be 
assiduously cleansed with antiseptic lotions and dressings. Xutritious 
diet and preparations of iron, quinine, and strychnine must be freely 
administered. Alcoholic stimulants may be sometimes required. 



CHAPTER XVIII. 

KOTHELN— GERMAN MEASLES. RUBEOLA. 

German measles is an epidemic, contagious disease, characterized by 
verv slight fever and catarrhal symptoms, with an eruption of pink- 
colored spots that resemble in some particulars the eruptions of both 
measles and scarlet fever. 

Symptom? and Course of the Disease. The period of incubation 
is of variable duration, lasting from seven to twenty-one days. The 
period of eruption is preceded by slight chills alternating with mod- 
erate fever, with loss of appetite, headache, and general discomfort, 
which may continue for a few hours only, or may be prolonged for two 
or three days. Moderate catarrhal symptoms affecting the eyes and the 
mucous membranes of the nose and throat, produce an increase of 
secretion, watery eyes, and sneezing. Sometimes there is a trifling 
cough. The temperature rises to 100° F.. or possibly in severe cases a 
degree or two higher, concurrently with the appearance of the eruption. 
The eruption appears first about the head and neck, and then invades 
the body and arms, appearing lastly upon the lower extremities, and 



ROTHELN GERMAN MEASLES. RUBEOLA. 229 

disappearing in the same order. The entire period of eruption is about 
four days, and at no time does it cover the entire surface of the body. 
The spots are punctate, rounded, discrete, and of a pink color. Their 
size is variable, many of them resembling the punctate elements of the 
rash in scarlet fever, while others approach in size the maculae of 
measles. They are but slightly elevated above the skin, and seldom 
assume the crescentic form. As they disappear, they fade more rapidly 
than the spots of measles. The tongue presents a white fur, and the 
membrane of the mouth and throat is slightly swelled and reddened, 
with spots suggesting the appearance of the similar eruption in measles. 
The lymphatic glands in the sides and back of the neck and in other 
parts of the body are somewhat enlarged. 

The subsidence of the eruption is followed by desquamation. This 
sometimes escapes observation, and is often very trifling in amount. It 
continues for one or two weeks, and is generally in proportion to the 
amount of fever and the intensity of the eruption. 

Catarrhal inflammations of the respiratory passages of the alimentary 
canal and of the kidneys are occasionally observed, but ordinarily the 
course of the disease is mild and free from complications. 

Etiology. Rubeola is propagated by a contagion which is probably 
transmitted in the same way that the similar contagions of measles and 
scarlet fever are conveyed. The exact nature of its active agent is not 
yet known, but it undoubtedly belongs to the bacterial class of para- 
sitic organisms. The disease prevails principally among children, for 
the reason that many adults have experienced its effects in childhood. 
It has been thought to be a hybrid form of disease, sharing in the 
characteristics of both measles and scarlet fever ; but careful observa- 
tion reveals its separate identity. It does not protect against either of 
the other diseases, and it does afford protection against itself. 

Diagnosis. The only diseases with which rubeola can be confounded 
are measles, scarlet fever, and the various forms of roseola. From 
roseola it may be distinguished by the history of the case, by its epi- 
demic prevalence, and by its lack of connection with previous infection 
by syphilis or by the ingestion of the drugs that produce roseolous 
eruptions. From measles it may be distinguished by the general mild- 
ness of the symptoms, and by the absence of the coryzal and febrile 
symptoms that so long precede the eruption of measles. The rapid 
course of the eruption, the lesser size of the spots, their brighter color 
and minor degree of elevation above the level of the skin, together 
with the absence of the crescentic form of the patches, serve to differ- 
entiate the rash of rubeola from that of measles. Within the mouth 
and throat the appearances more nearly resemble those of scarlet fever 
than those of measles. From scarlet fever rubeola may be distinguished 
by the brevity and mildness of the period of invasion, by the absence 
of vomiting and elevation of temperature, by the lesser degree of sore- 
throat, and by the swelling of the glands about the sides and back of 
the neck instead of those at the angles of the jaw which are principally 
affected in scarlet fever. The eruption of scarlet fever is more uniformly 
punctate than that of rubeola, and the desquamation of scarlet fever 



230 



PARASITIC AND INFECTIVE DISEASES. 



is far more extensive and flake-like than the fine, dusty exfoliation of 
rubeola. 

Prognosis. The uncomplicated disease is never fatal. Complica- 
tions affect the prognosis in proportion to their gravity. 

Treatment. Rubeola seldom requires any form of medication. 
The little patients are not even confined to bed, nor do they require 
the attendance of a physician. Severe cases that have been rendered 
such by the occurrence of complications may be treated in accordance 
with the rules laid down for the management of measles and of the 
special diseases that may have become intercurrent. 



CHAPTEE XIX. 

MEASLES— MOEBILLI. 

Measles is an epidemic, contagious fever, characterized by coryza, 
bronchitis, and a general eruption of slightly elevated, irregular, red- 
dened spots upon the entire surface of the body. 

Symptoms and Course of the Disease. The evolution of measles 
is characterized by four successive periods : incubation, invasion, erup- 
tion, and desquamation. 

Incubation. It is not possible to fix an exact and uniform duration 
for the period of incubation. It may vary from eight to fourteen days, 
though its usual length is about twelve days During this time the 
health may not be disturbed, but it is not uncommon to observe a cer- 
tain degree of depression of spirits, accompanied by slight fever. 

Fig. 83. 




Temperature in measles. Fall of temperature after the first day's fever. Great rise 
on the fourth day, with the appearance of rash. Maximum on fifth day, with full 
development of the rash. (Wunderlioh.) 

Invasion. This period is characterized by depression, muscular 
pains, loss of appetite, sometimes by vomiting, by irregular chills and 
fever, watery eyes, coryza, and a hoarse, dry cough. The conjunctivae 



MEASLES — MORBILLI. 231 

are injected, the eyelids are swelled, there is photophobia, and a copious 
discharge from the nasal mucous membranes ; sometimes there is nose- 
bleed ; sneezing is a frequent occurrence. The fever closely resembles 
that of acute catarrh ; it rises at night and intermits in the morning. 
The temperature seldom exceeds 102° F., and frequently returns to 
the normal point during the second day, rising again with the appear- 
ance of the eruption. (Fig. 83.) 

On the third or fourth day an eruption of circumscribed and slightly 
prominent patches may be discovered upon the soft palate and pillars 
of the fauces, and in the pharynx. This eruption appears from twenty- 
four to forty-eight hours before the rash can be discovered upon the 
skin. During this period the tongue is coated, there is thirst and 
complete loss of appetite, but the bowels ordinarily remain in their 
normal condition. 

Nervous symptoms are usually limited to a feeling of prostration, 
accompanied by headache ; delirium is rare. Young children some- 
times experience convulsions. The period of invasion usually lasts 
from three to four dtys. Sometimes only fever and coryza are present 
without the occurrence of cough. 

The eruption first appears upon the sides of the neck, upon the chin, 
about the lips, upon the cheeks and forehead. It consists of semi- 
circular, crescentic patches about the size of a grain of wheat, slightly 
elevated above the level of the skin, and of a deep-red color, which 
disappears on pressure, but is renewed as soon as the finger is removed. 
These patches sometimes remain isolated, but usually they become 
confluent to a degree that suggests the eruption of scarlet fever, espe- 
cially upon the face. Appearing upon the face and neck, it extends 
downward over the body and the limbs, reaching the extremities in 
from twenty-four to forty-eight hours. By this time the earliest por- 
tion of the eruption begins to decline ; the spots lose their vivid color, 
subside, and grow smaller. The color becomes dark and dull, and is 
only incompletely effaced by pressure. The decline of the eruption 
upon any given portion of the skin occupies from three to five days. 

During the period of eruption the fever continues until the subsidence 
of the rash, reaching its highest elevation with the complete generaliza- 
tion of the eruption ; it rapidly subsides with the fading of the rash. 
Catarrhal symptoms continue and sometimes are increased during the 
period of eruption. Respiration is somewhat accelerated, there is 
abundant muco-purulent discharge from the nostrils, cough continues, 
and during the outbreak of the rash there may be a slight dyspnoea ; 
symptoms of bronchitis are present, caused undoubtedly by the occur- 
rence of the eruption upon the mucous surfaces of the body. During 
certain epidemics the effects of the eruption upon the mucous membrane 
of the alimentary canal are sufficient to produce considerable diarrhoea 
in many patients. The duration of uncomplicated measles is about 
eight or nine days, of which three or four are occupied by the invasion 
and the remainder by the eruption. 

Desquamation. As the eruption disappears the epidermis becomes 
detached in the form of fine epithelial scales. These never assume the 



232 PARASITIC AND INFECTIVE DISEASES. 

magnitude of the epidermal shreds that are thrown off during the 
similar period in scarlet fever. They are sometimes scarcely noticeable. 

Varieties. During the period of invasion the fever may be ex- 
cessive. Coryzal phenomena may be greatly exaggerated. The cough 
may be excessive and suffocative, resembling the paroxysms of laryngis- 
mus stridulus. Diarrhoea may be present, and may become dangerously 
severe from the development of dysenteric symptoms. Vomiting may 
in like manner become a source of distress and danger. Intense head- 
ache, convulsions, stupor, and coma may cause great alarm, but these 
incidents are usually arrested by the appearance of the eruption. 
Sometimes the period of invasion may be prolonged for many days^ 
and, on the contrary, it may be considerably abridged. 

Eruption. The rash may be incompletely developed, remaining 
pale and indistinct, with a few spots visible upon the skin. In other 
cases the eruption may be intense and confluent. Its duration may be 
greatly abbreviated, with true disappearance of the spots in a few 
hours. It may appear upon the body before it is manifested upon the 
face. The spots themselves may sometimes become unusually prom- 
inent, without disappearance on pressure, indicating a certain amount 
of inflammatory exudation into the skin. Small vesicles surrounded 
by an areola appear among the spots of the normal eruption. A cer- 
tain amount of cutaneous irritation is usually present. Catarrhal 
symptoms are sometimes almost completely absent. In like manner 
the fever is sometimes almost imperceptible in mild cases of the disease. 

Malignant measles is characterized by great severity of fever, intense 
headache, repeated vomiting, violent diarrhoea, frequently by convul- 
sions and coma. The temperature is high, the tongue dry and brown, 
and the patient may die before the appearance of the eruption. If life 
be prolonged, the eruption may be irregular in its appearance, and may 
be imperfectly developed or may assume the hemorrhagic form, charac- 
terized by a dark-purple color, and by the appearance of petechia? and 
of hemorrhages from the mucous membranes. The patient usually dies 
in a few days, overwhelmed by the disease that runs its previous course 
with, or without, complications. 

Complications. The complications of measles consist either in an 
exaggeration of the normal phenomena of the disease, or of the result 
of the direct action of the contagion upon the tissues, producing 
unusual phenomena, such as hemorrhage, gangrene, and infective dis- 
eases of the internal viscera. In addition to these complications, other 
diseases, such as diphtheria, scarlet fever, tuberculosis, etc., may 
become associated with measles. 

The most frequent and dangerous complications of the disease are 
the various disorders of the respiratory organs. Capillary bronchitis 
and broncho-pneumonia, laryngitis and chronic catarrhal affections, are 
the most common among the respiratory diseases. Various forms of 
inflammation may invade the mouth and the alimentary canal. The 
diarrhoea that sometimes accompanies the fever may result in the estab- 
lishment of chronic entero-colitis. Diseases of the circulatory appara- 
tus, such as pericarditis, endocarditis, and phlebitis are rare, but have 
been occasionally observed. As in other infective diseases the blood 



MEASLES — MORBILLI. 233 

may become incapable of forming a clot, and the red corpuscles lose a 
considerable portion of their haemoglobin. Hence the tendency to 
hemorrhage that is sometimes witnessed. 

Dropsy is of rare occurrence after measles. 

Among unhealthy children gangrene sometimes complicates the dis- 
ease. It sometimes appears during the period of eruption, but more 
frequently after its subsidence. It commonly attacks the mouth along 
the borders of the gums or in the cheek near the orifice of the duct of 
Steno. The lungs, the female sexual organs, the ears, and ill-nour- 
ished portions of the skin upon different parts of the body, may also 
become the seat of gangrene. 

The mesenteric glands and the bronchial glands may become the 
seat of inflammation, and tuberculosis is a not uncommon consequence 
of measles. Subcutaneous abscesses and pyemic symptoms are some- 
times observed. 

Transient albuminuria is not uncommon during the course of the 
disease. Actual nephritis is rare. Like other infective diseases, 
measles is sometimes followed by paralysis, involving more or less of 
the nervous system. 

Chronic conjunctivitis and chronic otitis are frequent sequelae of the 
disease. Tubercular diseases ot the bones, joints, and other structures 
of the body, not unfrequently follow the course of measles. 

Relapses of measles are occasionally observed. A mother may some- 
times be seen in bed with her children, suffering a second attack, caused 
by the same contagion that has prostrated her offspring for the first 
time. This proclivity to the disease apparently increases with the 
lapse of time. 

Diagnosis. During the period of invasion it is difficult to distin- 
guish measles from influenza. Vomiting is usually more frequent in 
measles than in influenza, and the epidemic environment often throws 
light upon the probable character of the attack. From typhoid fever 
it may be distinguished by its more rapid progress, and by the early 
appearance of the characteristic eruption. The temperature curve is 
also different in the two diseases, as may be seen by a reference to the 
diagrams of temperature. 

From meningitis the disease may be distinguished by the catarrhal 
symptoms. Scarlatina differs from measles by the absence of coryza, 
by the intensity of the fever, by the burning heat of the skin, by the 
constant elevation of the temperature, and by the diffused redness of 
the soft palate, tonsils, and fauces ; while the redness of measles is more 
conspicuous in the pharynx. At a later period the eruption within 
the mouth, in measles, resembles that upon the skin, while in scarlet 
fever there is a uniform redness of the mucous membrane. Smallpox 
can only be considered as a possibility before the period of eruption. 
It may then be distinguished from measles by the minute, indurated, 
shot-like papules that can scarcely be confounded even with the rounded 
and slightly indurated papules that sometimes appear in measles. The 
eruption of smallpox soon becomes vesicular, while that of measles 
never passes beyond the papular stage. The eruption of scarlet fever 
is punctate, and tends to become rapidly confluent, while the eruption 



234 PARASITIC AND INFECTIVE DISEASES. 

of measles, even though it be confluent, preserves its elevated, macular. 
and crescentic form. The eruption of measles is most conspicuous 
upon the face, where that of scarlatina is less prominent. The color of 
the rash in measles is darker than that of scarlatina. The miliary, 
Uar, and other eruptions that sometimes coexist with the rash of 
measles, do not extend over the whole surface of the body, and may 
thus be readily distinguished from similar eruptions of independent 
origin. 

The papular forms of erythema sometimes appear upon the neck. 
chest, arms, and backs of the hands. The eruption is sometimes pre- 
ceded by a trifling fever, but the other characteristics of measles are 
absent. 

Roseola and Grermam measles often present a superficial resemblance 
to measles, bat The febrile Hioveruenr is less severe : caTarrhal symp- 
Toms are almost entirely absent, and the eruption is less prominent 
above The level of The skin Than in measles. Certain syphilitic erup- 
tions may somewhat resemble that of measles, but the history and 
course of the disease will soon enlighten the diagnosis. Medicinal sub- 
stances, such as quinine, iodide of potassium, and the terebenthinate 
preparations, produce eruptions, which, however, may be distinguished 
from measles by the absence of fever and catarrhal symptoms, and by 
the cutaneous irritation that they produce. 

Etiology. The contagion of measles is exceedingly diffusible. It 
may be transmitted through the atmosphere, and may enter the circu- 
lation through the respiratory organs. This is the most common means 
of transmission. Few persons can inhale air infected by a sufferer from 
measles wkhouT thus contracting the disease. It may also be commu- 
nicated by direct contact, and it has been caused by inoculation with 
blood or with the secretions of a morbillous patient. AVhen thus trans- 
mitted, the period of incubation is about nine or ten days. The erup- 
tion follows about three days later. The effluvia of the patient appear 
to be infective from the commencement of the prodromic symptoms 
until convalescence is fully established. In the blood and in the excre- 
tions, especially in the nasal mucus, of patients suffering with measles 
may be found great numbers of mi . especially diplococcus and 

a variety of streptococcus. These probably are the most important of 
the bacterial parasites which flourish abundantly in the fluids of an 
infected person. 

PATHOLOGICAL Anatomy. It is in the respiratory organs that the 
most conspicuous changes may be observed after death. Inflammation 
of the nasal passages, pharynx, trachea, and bronchi may exist with every 
grade of intensity — from mere hyperemia to ulceration and *al- 

\rrhal pneumonia is exceedingly common, while lobar pneumonia 
is rare. A rene of the lungs sometimes occur ; tu ; 

organs is not unfreqnent. The pleural 9 may also 

be involved. Endocarditis and pericarditis sometimes occur. The 
blood becomes impoverished, its fibrin diminishes, and the haemo- 
globin dissolves out of the red corpuscles. The peribronchial lym- 
phatic glands and the vnds become enlarged and softened: 
the spleen is also enlarged The kidneys rarely manifest signs of dis- 



MEASLES — MORBILLI. 235 

ease. Inflammation, ulceration, and gangrene of the oral and pharyn- 
geal cavities have been observed in cachectic patients. The mucous 
membranes of the alimentary canal may exhibit evidences of inflam- 
mation, especially in the large intestine and in the rectum. 

If ophthalmia or otitis have been present, the effects of these diseases 
■will be apparent after death. 

Prognosis. Uncomplicated measles occurring in ordinarily healthy 
subjects is rarely fatal ; its irregular, exaggerated, and complicated 
forms are exceedingly fatal. Very young children are liable to death 
from pulmonary and intestinal complications. Social misery, pre- 
existing cachexia, unfavorable conditions of weather and climate, add 
greatly to the dangers of the disease. It is consequently extremely 
fatal among soldiers and sailors who are frequently predisposed to 
scurvy, and in whom measles frequently assumes hemorrhagic and 
malignant forms. In such cases a mortality of thirty or forty per cent, 
is not uncommon. Under favorable conditions the mortality seldom 
exceeds two per cent. If, however, the sequelae of the disease be taken 
into consideration the mortality may be estimated at about ten per 
cent. The incidence of measles, however, is not an unmixed evil, for 
functional nervous diseases and certain chronic skin diseases are fre- 
quently cured by its intervention. 

When the disease becomes epidemic for the first time in a popula- 
tion that has never experienced its effects, the mortality is very great. 
Thus, at the Sandwich Islands, when it was first introduced, in 1848, 
ten per cent, of the population were sw T ept away by the epidemic. At 
the Fiji Islands, in 1877, a similar first experience of measles destroyed 
20,000 people in a population of little more than 100,000 souls. This 
great mortality was the result of complicating diseases rather than of 
the infective disease itself. 

Treatment. Simple uncomplicated measles requires very little 
medication. Hygienic care and attentive nursing are the principal 
requisites. Milk, gruel, and thin broths should be used for nourish- 
ment. Moderately cool and abundant drink 'may be given to the pa- 
tient, and occasional sponging with tepid water may be allowed if it be 
agreeable. The room should be darkened, and the eyes should be fre- 
quently bathed with warm water, to relieve the conjunctival swelling. 
Antipyrine in appropriate doses may be given during the febrile period. 
Dover's powder may be administered at night, to procure restful sleep. 
The cough may be alleviated by the ordinary mixtures for bronchial 
catarrh, but if the symptoms of capillary bronchitis are present, opiates 
should be avoided. In such cases large poultices should be applied to 
the chest, and ipecac may be given until the expectoration is copious. 
During convalescence the return to solid food should be gradual, and 
exposure to cold must be avoided. Errors in these particulars are 
often followed by intestinal and pulmonary inflammations . that are 
frequently fatal. 

Malignant forms of the disease demand more energetic treatment. 
If the fever be intense, with delirium and symptoms of nervous irrita- 
tion, and if eruption be delayed, much benefit may be obtained from 
the use of baths. The patient may be placed in a warm bath, of which 



Z3b PARASITIC AND INFECTIVE DISEASES. 

the temperature is a little less than that of the body. The wet pack, 
with a sheet dipped in warm water, forms a very efficient means of 
inducing the eruption when that is unusually delayed. Convulsions 
during the period of invasion are ordinarily of trifling importance : if 
repeated they may be quieted with bromide of potassium and chloral. 
The same remedies will be found useful in the attacks of laryngismus 
that sometimes complicate the earl 1 of the disease. Hemor- 

rhagic symptoms require the administration of astringents, of which 
aromatic sulphuric acid is the most efficient. Typhoid tendencies must 
be opposed by the use of stimulants combined with milk and eggs, in 
the form of egg-nog. Premature recession of the eruption calls for the 
application of warmth externally, and for the administration of warm 
and stimulating drinks. Aromatic spirits of ammonia, spirits of chloro- 
form, and the ordinary alcoholic stimulants will be of service in such 
cases. In the treatment of very young children opiates should be 
led as far as possible, in consequence of the susceptibility of such 
patients to the poisonous influence of opium. Complicated diseases 
must receive the treatment appropriate to each case. 



CHAPTER XX. 

SCARLET FEVER— SCARLATINA. 

Scarlet fever is a contagions lisease, characterized by high fever : 

lion that continues about one week on the surface of the 

body: and by inflammation of the tonsils and the adjacent lymphatic 

glands. It is sometimes complicated with rheumatism affecting the 

is often followed by various sequelae, of which the most 

rant is inflammation of the kidneys. 

Symptoms and Description of the Disease. The incubation of 

the disease is of variable duration. Children ex the contagi 

do not manifest the symptoms of infection with any degree of uniformity 

as : time. As a general rule, however, the duration of the period of 

incubation is from three to seven days. During this time the patient 

usually appears to enjoy ordinary health. Sometimes slight disorders 

may be apparent, but as a general thing the invasion of the 'lisease is 

abrupt. The child may have been all day at play : retires to bed. 

apparently as well as usual, and before midnight may be tossing in a 

burning fever. Nausea and vomiting without previous evidence of 

gastric die ften accompany and mark the invasion of the dis- 

The pulse rapidly increases its frequency : the temperature rises 

• ; F. : the sfc ; the throat burns and 

infill during the act of deglutition: the tongue is covered with a 

thin white fur. and is red at the tip and _ - Pulmonary symptoms 

are absent : the bowels are usually constipated. The patient seems 

dull and inclined to sk onetimes conv cur. At the ex- 






SCARLET FEVER — SCARLATINA. 237 

piration of twelve to twenty-four hours the eruption begins to appear. 
This consists of minute red points that are not elevated above the skin, 
and are separated, at first, by intervals of healthy epidermis. In mild 
cases they remain thus segregated, but in the severer forms of the dis- 
ease these points soon coalesce, giving a uniformly scarlet appearance 
to the surface of the body. Sometimes the eruption presents a slightly 
purplish tint like that of raspberry juice. In certain cases the points 
of eruption are slightly elevated above the surface and may occasionally 
present minute vesicles at their apices. 

The eruption usually makes its first appearance about the neck, 
whence it spreads to the face and over the surface of the body and the 
limbs. The face and the hands not unfrequently escape till a late 
period, or present a less vivid form of eruption than that appearing upon 
other parts of the surface. It is most conspicuous upon the cheeks, 
which frequently contrast their color with the persistent whiteness of 
the skin around the mouth. It also appears upon the pillars of the 
fauces and upon the soft palate. In general terms it may be described as 
most abundant where the skin is the thinnest. Although the eruption 
does not rise above the level of the surface, the skin is somewhat tume- 
fied by its occurrence ; the face and hands and feet consequently appear 
somewhat swelled. This swelling disappears with the eruption and 
must not be confounded with the subsequent rheumatic swelling of the 
joints. 

The evolution of the eruption occupies from one to three days. It 
remains fully efflorescent for about twenty-four hours, and then grad- 
ually subsides during an equal period of two or three days. During 
the whole of this time the patient complains of considerable itching 
and burning of the skin. This is a source of much discomfort. 

During the first day the tongue remains moist and covered with a 
white fur, which gradually disappears by the fourth or fifth day, leav- 
ing the organ red, swollen, and covered with prominent papillae, some- 
what resembling the surface of a strawberry, whence the term straiv- 
berry tongue that characterizes this phase of the disease. As the 
eruption subsides the tongue becomes reduced in size, the papillae 
diappear, and the normal covering of epithelium is gradually re- 
stored. The tonsils are more or less swelled, and the orifices of the 
mucous follicles are visibly filled with muco-purulent secretion. The 
sub-maxillary and cervical lymphatic glands share in the tonsillar 
enlargement. The burning fever that marked the commencement of 
invasion continues to increase with the progress of the eruption. It 
frequently reaches 105° or 106° F., and continues at an elevated 
point until the subsidence of the eruption. Defervescence is not sud- 
den, but is gradual, with morning remissions and evening exacerba- 
tions. The course of the pulse is parallel with that of the temperature, 
rising rapidly at the commencement of the fever and sinking gradually 
with its subsidence. In like manner the respiratory movements are 
accelerated and retarded with the course of the fever. The respiratory 
passages are usually healthy, though the extension of the eruption into 
the nasal and pharyngeal orifices causes a moderate coryza which, in 
severe cases, may lay the foundation of intense inflammation and 



238 PARASITIC AND INFECTIVE DISEASES. 

ulceration. During the eruptive period the urine presents only the 
characteristics of the febrile state. It is scanty, high colored, and 
charged with urates and phosphates. 

Desquamation. As the eruption disappears, exfoliation of the 
epidermis begins. After an intense fever with abundant and vivid 
eruption, desquamation commences, even before the complete disap- 
pearance of the eruption. The surface of the skin becomes dry and 
rough: minute scales composed of dead epithelium are thrown off; 
sometimes the epidermis is detached in considerable flakes : occasionally 
it is thrown off in large casts from the hands and fingers, after the 
manner of a serpent shedding its skin. Occasionally the hair and the 
nails are thrown off during the period of desquamation. In mild 
forms of the eruption desquamation is very trifling and soon com- 
pleted, but when the eruption has been copious, with a high fever, it 
may be prolonged for six or eight weeks. Ordinarily it is completed 
within three weeks. "Where the skin is thick, as upon the hands and 
upon the feet, the epidermal flakes arc large and glove-like, while 
upon those portions of the body where the skin is thin and delicate it 
assumes a furfuraceous character like that of measles. 

Irregular Forms of Scarlet Fever. Though scarlet fever usually 
follows the lines of evolution just indicated, it often appears in irregular 
forms. Xo disease can be more variable in its intensity. It may 
assume a form so insignificant as to be almost beneath recognition : or. 
again, it may manifest itself as one of the most violent and fatal of dis- 
eases. Sometimes the period of invasion is almost absent : there may 
be no fever, and the eruption may be the first symptom of the disease. 
The eruption may. in certain cases, be entirely absent, or be so insig- 
nificant as to escape observation. In other cases the period of invasion 
is prolonged for a number of days. Sometimes there may be severe 
nervous symptoms, such as delirium, convulsions, stupor, difficulty of 
breathing, all of which disappear when the eruption breaks out. In 
some cases the rash does not cover the whole body, but appears in 
irregular patches, which are frequently of a purple hue. instead of the 
normal scarlet of the benign form of the eruption. Such cases are 
often attended by severe and dangerous nervous symptoms terminating 
in death. This form must be distinguished from mild cases with a 
discrete eruption in which the punctate spots are separated from one 
another by intervals of comparatively healthy skin. Hemorrhagic 
torms of the disease are characterized by petechia?, or even by ecchy- 
motic patches In certain rare cases the first eruption may disappear^ 
and may be followed, after a few days, by a second, or even by. a third 
eruption. Such relapses after apparent recovery may sometimes prove 
fatal. The condition of the mouth and the throat may. in like manner, 
vary with the different forms of the disease. The whole lining of the 
mouth and throat may be swelled, scarlet in color, presenting evidences- 
of acute inflammation in the tonsils and about the fauces. After two 
or three days the tonsils, and sometimes the pharyngeal walls, become 
covered with a white or gray exudation. This may penetrate into the 
submucous tissues, causing the development of abscesses in the tonsils, 
or in the adjacent tissues, burrowing deeply into the neck. The lym- 



SCARLET FEVER — SCARLATINA. 239 

phatic glands outside of the cavity of the mouth and of the pharynx 
share in the inflammation, sometimes causing immense swelling of the 
neck, with a brawny hardness like that of uncooked bacon. This pro- 
cess of glandular tumefaction progresses gradually, and does not sub- 
side with the disappearance of the eruption. It is clue to an intense 
grade of blood-poisoning, and may lead to the most serious results. 

Catarrhal inflammation of the bronchial mucous membrane and of 
the g astro-intestinal mucous membrane are sometimes observed as 
complications of the disease. 

Malignant Scarlet Fever. The term malignant is applied to those 
forms of the disease that are characterized by excessive intensity, by 
an unusual sequence of symptoms, by excessive prostration, or by the 
occurrence of severe and unusual complications. Sometimes the patient 
dies suddenly, after a very brief period of invasion characterized by 
intensity of fever, violent headache, severe vomiting, delirium, and 
coma. In young children convulsions are extremely liable to accom- 
pany this form of the disease. In other cases the patient sinks rapidly 
into a typhoid condition, characteriz ed by dry and brown tongue, weak 
and rapid pulse, distention of the abdomen, dilatation of the pupils, 
stupor, coldness of the extremities, irregular distribution of bodily heat, 
complete collapse, and death. These cases are very frequently compli- 
cated with hemorrhages from all the orifices, and into all the tissues of 
the body. In other cases violent vomiting and diarrhoea rapidly prostrate 
the patient, who soon dies in a state of collapse. Occasionally the disap- 
pearance of eruption and the subsidence of fever are speedily followed by 
the symptoms of meningeal inflammation, which soon terminates the life 
of the patient. Catarrhal inflammation, involving the respiratory pas- 
sages and the alimentary canal, has already been mentioned among the 
complications of scarlet fever. A kindred form of inflammation attack- 
ing the renal structures is frequently observed among the sequelae of 
the disease. It is more frequent in certain epidemics than in others. 
It may follow the mildest forms of the disease as well as severer cases. 
Its occurrence may sometimes be the first indication of the existence of 
scarlatina in an individual case that has been characterized by absence 
of the usual eruption. As a complication it occurs more frequently 
after scarlet fever than after any other disease. It often manifests 
itself in cases where every precaution against exposure to the usual 
causes of nephritis has been taken. In other cases it is absent, not- 
withstanding every possible degree of negligence. It occurs during 
the period of desquamation, and sometimes is ushered in by fever, head- 
ache, nausea, and vomiting, and the usual symptoms of an inflamma- 
tory fever. In other cases the appearance of anasarca is the first 
symptom that attracts attention to the condition of the kidneys. This 
complication will be fully considered in connection with diseases of the 
kidneys. It occasionally happens that inflammation may attack the 
pericardium or the endocardium. This complication frequently occurs 
in connection with articular inflammations which are usually attributed 
to rheumatism. Scarlatinal rheumatism is generally observed as the 
eruption disappears. It attacks the joints of the fingers and wrists ; is 
usually quite transient in its duration, but may sometimes become 



PARASITIC AND INFECTIVE DISEASES. 

rged in a process of intra-artieular suppuration. Such 
are. h to be considered as local manifestations vhich 

illy occurs as a sequel of scarlet fever. 
>t nay ale in rare instances occur as a sequel of scarlet 

fever. It is most commonly observed among ill-fed children, and other 
victims of cachexia. It may attack the extremities of the finders or of 
the toes, the tips of the ears, the point of the nose, the lips, the tongue, 
the ex: xual organs. dona of the body subjected to unusual 

pressure in bed: it may invade the larynx, the eyeballs, the intestinal 
canal, the "-sues of the lungs, and the areolar tissue of the neck. 
Among the mos: dangerous complications of scarlet fever must be reek- 
It may occur as an exaggeration of the severer forms 
osillar and pharyngeal inflammation : and it may be difficult to 
distinguish between the ses. It may also occur, apparently. 

as a sequel :: m rlet fever: in which case, however, it should be 
Led as an independent disease, following rapidly after the subsi- 
:: scarlatina. Such concurrence of the fcwc la greatly 

to die risks >f the | atient More than fifty per cent, of such cases 
we fatal. 

Like other infective diseases, scarlet fever is sometimes followed by 
various forms of nervo-muscular disease. X I la and neuri&u 

and the muscles of the neck may become involved, producing 

As scarlet fever is frequently followed by othc ifi aes, so it also 
may occur as a secondary It may thus become associated 

with measles. wh>; : ing- ugh. typhoid fever, and other eruptive 
e aes. It may occur after wounds, :: surgical operations, or after 
childbirth, even where no apparent exposure to its 2 n can be 

DlA 1NOSIS. Scarlet fever may be distinguished from simple sore- 
it by the eruption, which is lacking in faucial inflammation. T - 
i " 'is usually commences upon one side, while the faucial eruption of 
scarlet fever is bilateral and universal. From diphtheria it may be 
the more abrupt commencement, and by the character 
of the eruption upon the surface of the body. From ! it maybe 

_ ished by the absence of eoryza and cough, and by the char 
of the eruption, which is put instead oi being papular, and > 

elevated above the level of the skin. In measles the eruption is slightly 

rescentic in the arrangement of its papules upon the - 
of the neck, and covers the whole lace up : the lips, 

while the eruption of scarlet fever generally respects those parts. Some 
difficulty may occur in cases of scarlet fever complicated by catarrhal 
symptoms : but these are rare, and the rac f the disease will soon 
clear up the di _ 

fi i - semble scarlet fever in the form of 

the erupt: they are much less severe. Their duration is less, and 

the subsequent des n is very trifling in c - d with tl 

scarlet fever. i may produce eruptions which closely 

resemble that of scarlet fever. Belladonna, hyoscyamus, stramonium, 
and antipyrine may thus produce an eruption closely resembling that 



SCARLET FEVER — SCARLATINA. 241 

of the infective disease ; but the history of the case and its course 
will soon clear up the diagnosis. 

Etiology. Scarlet fever is communicated by means of contagious 
particles that are given off from the body of the patient during the 
entire course of the disease and until the cessation of the process of 
desquamation. The contagion may be carried by the atmosphere to a 
short distance. It may be transmitted to indefinite distances by adhe- 
sion to articles of clothing and other things that have been in contact 
with the patient. It is readily absorbed by milk, which has thus 
frequently become the vehicle of transmission from infected localities to 
consumers of the article. The duration of the period during which con- 
tagion may be given off by a convalescent patient is extremely variable. 
Well-authenticated cases are recorded in which patients were infective 
for two or three months after the original attack. 

Though dependent upon contagion for its propagation, the disease is 
much more prevalent during cold and damp weather than during the 
mild season of the year. Its fatality is greatest during the severe 
weather of the winter months. Extremes of every kind that affect the 
weather serve to increase the fatality of the disease. 

The epidemic prevalence of scarlet fever in a population where it is 
constantly present, follows a very regular course. Epidemic waves 
follow one another at intervals of five to seven years, each epidemic 
period requiring about two years for its complete evolution. 

Scarlet fever is a disease that prevails in cold climates. If the con- 
tagion be transmitted to the tropics it speedily loses its activity, and 
the disease does not become epidemic. It is said that it has never pre- 
vailed in Japan. In certain countries, its fatality is greater than in 
others, as in England it is more dangerous and deadly than in France. 

All ages and sexes are subject to the disease, though it is rare among 
nursing infants. It is also uncommon among adults, though principally 
for the reason that many of them have experienced the disease in child- 
hood. It is most common among children from three to ten years of 
age. The lymphatic temperament seems to act as a predisposing cause 
of the disease. 

Not all who are exposed to scarlet fever will contract the disease. 
Probably not more than fifty per cent, in any community are susceptible 
to the contagion. The cause of this immunity is not understood, but 
its existence is certain. For this reason the supposed effect of specific 
remedies as a means of prevention and protection against the disease is 
rendered very questionable. Various drugs have been administered for 
prophylactic purposes, but their apparent success is for the most part 
due to natural immunity on the part of so many members of the com- 
munity. When the disease appears in a family of children, it is not 
unusual to observe its tardy manifestation among the members of the 
family, with long intervals between the successive cases, although no 
efforts may have been made for separation of the healthy from the 
sick. Something more than mere exposure to the contagion seems to 
be necessary in many cases. 

Bacteriological examination of the tissues, after death from scarlet 
fever, reveals the presence of numerous forms of bacteria. Of these, 

16 



242 PAKASITIC AND INFECTIVE DISEASES. 

the most common is a variety of streptococcus pyogenes. It is yet im- 
possible to say that this is the only active agent in the contagion of the 
disease, but it certainly is one of the active agents. 

Pkognosis. Simple, uncomplicated scarlet fever is not dangerous. 
Its mortality does not exceed four to six per cent. But the malignant 
and complicated forms of the disease are exceedingly fatal. Indica- 
tions of danger are furnished by convulsions, by excessive vomiting, by 
high fever, intense, irregular, and livid eruptions, especially if accom- 
panied by petechiae or hemorrhages. Great prostration and the typhoid 
condition, stupor, severe complications — especially diphtheria, pysemia, 
suppuration in the neck, purulent accumulations in the pleural cavity 
or in the articulations, cardiac disease, albuminuria, and anasarca — all 
indicate great danger. Secondary forms of the disease that occur 
subsequent to childbirth, wounds, or surgical operations, are more 
dangerous than the primitive form of the disease. Children under five 
years of age experience a higher degree of mortality than older per- 
sons. 

Pathological Anatomy. The seat of the eruption in scarlet fever 
is in the network of lymphatic vessels beneath the epidermis. It also 
involves the capillary vessels of the skin, causing hyperemia and an 
exudation between the layers of the epidermis. In this way is produced 
the swelling of the skin which marks the severer forms of the eruption. 
The distention of the capillary vessels produces the punctate appearance 
of the early stage of the eruption, and its confluence in the completed 
evolution of the rash. So long as the capillary vessels remain intact, 
the eruption may be made to disappear on pressure ; by their rupture are 
produced local hemorrhages, petechia?, and ecchymotic spots. As the 
eruption subsides, the lymph that was effused between the layers of the 
epidermis is absorbed, the external epithelial layer dries and becomes 
separated from the deeper portion. By this process, desquamation is 
effected. By a similar process the tongue parts with its fur, and the 
fauces and pharyngeal cavity present the characteristic changes that are 
witnessed. In severer cases, stomatitis, ulceration, and gangrene may 
occur in the cavities of the mouth and throat. Similar changes may be 
noted in the mucous membranes of the alimentary canal. Peyers 
patches and the mesenteric ganglia are frequently enlarged ; the liver, 
the pancreas, and the spleen are also increased in volume. The liver 
sometimes exhibits evidences of inflammation. The cavities of the 
joints present changes identical with those produced by inflammatory 
rheumatism. The serous cavities of the body are frequently occupied 
by a serous transudate during the course of the anasarca that is caused 
by a nephritis ; they may become inflamed, and they may contain a 
purulent exudation. Endocarditis and myocarditis, like those follow- 
ing rheumatism, are occasionally discovered. The kidneys rarely pre- 
sent any evidence of disease before the period of desquamation. 
Their inflammation is usually of the catarrhal form, involving the 
epithelium of the uriniferous tubules. Interstitial inflammation, in- 
volving the arteries, lymphatics, and veins of the organ, is not uncommon. 
In the respiratory organs coryza is comparatively frequent ; laryngitis, 
bronchitis, and pneumonia are occasionally observed. The Eustachian 



SCARLET FEVER — SCARLATINA. 243 

tube and the auditory passages may become involved by continuity with 
the nasal and pharyngeal cavities. Meningitis, meningeal dropsy, 
cedema of the brain, and similar conditions of the spinal cord, have 
been occasionally observed ; but the majority of the nervous disturb- 
ances that complicate scarlet fever leave slight traces visible after death. 
The blood, as in other infective diseases, is indisposed to coagulate, and 
its haemoglobin is largely dissolved out of the red corpuscles. 

Treatment. — The general course of nursing in scarlet fever is more 
important than its medication. The patient should be isolated, and 
should be kept in bed, even though the case be of a mild character. 
The diet should be liquid, and an abundance of water must be supplied 
for drinking. The itching of the skin, which forms so unpleasant an 
incident, may be greatly relieved by gentle friction with any oleaginous 
substance. The surface of the body, during the febrile stage, may be 
frequently sponged with water of the temperature that is most agree- 
able to the individual, and may then be lubricated with oil or vaseline. 
Mild cases require little or no medication, unless it be some gentle 
hypnotic in order to aid sleep at night. Restlessness and nervous irri- 
tability may be relieved by frequent exhibition of minute doses of 
opium or its derivatives. Vomiting generally ceases with the appear- 
ance of the eruption, and may be relieved by the use of ice and lime- 
water with, or without, milk. If vomiting persist or occur at a late 
period of the disease, it is an evidence of nervous complications, and 
may require more energetic treatment. In such cases bromide of 
potassium may be used with benefit. Fever may be treated with anti- 
pyrine or with phenacetine. Antipyrine is the preferable drug for 
young children on account of its solubility, but it must not be pressed 
to the point of producing nausea or excessive reduction of temperature. 
If the temperature rise above 103° F., the safest and most efficient 
method of treatment consists in the use of cold water. Cold shower- 
baths and immersion in a cold bath cause excellent results, but popular 
prejudice renders this method difficult of application in private prac- 
tice. In such casas the application of cold, by means of a wet sheet 
or by the use of Leiter's coils, secures the result with less antagonism 
from the public. The inflammation that occurs about the fauces re- 
quires but little treatment in mild cases. A solution of chlorate of 
potassium is generally sufficient. Patients who are old enough to 
gargle may use such a solution, or a one per cent, solution of chloride 
of sodium as a gargle. A two per cent, solution of boric acid in 
glycerin may be painted over the fauces every two or three hours. 
Vaseline similarly charged with the acid is very useful. Younger 
children may have their throats syringed with these solutions as fre- 
quently as may be necessary to prevent accumulation of decomposing 
exudations. For purposes of disinfection a solution of boric acid, of 
borax, or of permanganate of potassium are among the safest and most 
efficient. Eucalyptol and Listerine, which contains both eucalyptol 
and boric acid, are of considerable value. Swelling of the neck must 
be treated with poultices, and in accordance with the general principles 
of surgery. Coryza, otitis, and all inflammatory complications con- 
nected with the naso-pharyngeal passages, should be treated with great 



244 PARASITIC AXD INFECTIVE DISEASES. 

assiduity in order to prevent destruction of the auditory apparatus. 
Intercurrent diseases require the treatment appropriate for each one. 
Rheumatism seldom needs any special attention beyond the application 
of anodyne liniments, and protection of the affected joints by wrapping 
them with flannel and oiled silk. During convalescence the process of 
desquamation may be aided by frequent inunctions with vaseline, and 
by the use of soap containing eucalyptol, or salicylic acid, or boric 
acid. Constipation must be prevented : the patient must be guarded 
against cold : and the urine must be frequently examined in order to 
obviate the danger of nephritis. The treatment of inflammation of 
the kidneys will be considered in connection with the diseases of those 
organs. 



CHAPTER XXI. 

WHOOPING-COUGH-- PERTUSSIS. 

Whoopixg-cough is an epidemic, infective catarrhal affection of the 
respiratory organs, characterized by a peculiar spasmodic cough. 

Symptoms. The course of the disease may be divided into four 
stages: 1. The stage of incubation. 2. The catarrhal stage. 3. The 
spasmodic stage. 4. Decline and convalescence. 

Incubation. The stage of incubation varies from six to fourteen 
days. 

Catarrhal stage. This stage is ushered in with the symptoms of an 
ordinary cold. There may be slight fever, headache, and depression, 
sneezing, chilliness, and a moderate degree of swelling of the eyelids 
with suffusion of the eyes. These symptoms may continue for a vari- 
able period of time, lasting from two clays to three weeks or more, 
without the occurrence of anything decisive regarding the nature of 
the cough. If. however, it be unusually harassing and intractable, and 
especially if it be more frequent and irritating during the night than 
during the daytime, the probability of whooping-cough may be sus- 
pected. 

Spasmodic stage. The paroxysms of the cough now become more 
violent and protracted, though sometimes less frequent than during the 
catarrhal stage. During the intervals between the paroxysms the 
patient may appear to suffer comparatively little, but the advent of 
each paroxysm is preceded by a sensation of precordial distress and 
of irritation in the larynx and trachea. The movements of respiration 
then become accelerated, irregular, and restricted in their duration. 
The little patients seem to stifle their cough until it can be no longer 
restrained. They instinctively cling to their mothers or nurses, or 
seek to support themselves by grasping the furniture or anything 
within their reach. The paroxysm of cough finally explodes with a 
series of successive expiratory spasms, until the lungs are emptied of 
all the air that can be expired. The face becomes purple and swelled: 






WHOOPING-COUGH — PEKTUSSIS. 245 

the eyes are reddened, and appear as if about to spring from their 
sockets; the superficial veins of the head and neck become prominent; 
the heart beats violently ; perspiration breaks out over the head and 
upper portion of the body, and suifocation appears to be imminent. 
This expiratory spasm is immediately followed by a few partial attempts 
at inspiration, instantaneously succeeded by a long, noisy, whistling 
whoop that fills the lungs with air and terminates the first stage of the 
paroxysm. A number of similar spasmodic respirations follow ; usually 
continuing until a quantity of glairy, viscid mucus is expectorated 
from the pharynx ; or until, as sometimes happens, the contents of the 
stomach are evacuated by vomiting. The paroxysm is thus terminated 
after a duration of one or more minutes. The patient seems then to be 
perfectly relieved, and resumes his occupations, or falls asleep if the 
paroxysm have occurred during the night. Similar paroxysms recur 
during each day and night ; usually more frequent during the night 
than by day, occurring at intervals of an hour, or half an hour, or 
every few minutes. Their intensity and their number continue to 
increase for two weeks or longer. 

During the spasmodic stage the patient is generally free from fever ; 
and, if complications are absent, comparatively little discomfort may 
be experienced during the intervals that are free from cough. Auscul- 
tation of the lungs indicates very little disturbance of respiration, only 
a few hoarse rales being audible in the bronchi. Similar auscultation 
during the paroxysm of cough discovers no vesicular murmurs or 
respiratory sounds excepting at the moment of inspiratory spasm. 

In severe cases of the disease blood may escape from the nose and 
from the mouth, and even from the ears, during the paroxysms. 
Minute vessels may rupture beneath the conjunctiva, or in the loose 
areolar tissue of the eyelids, causing subcutaneous or sub- conjunctival 
hemorrhage. Violent paroxysms of sneezing may occur in addition 
to the cough. Urine and feces may also be expelled during the violent 
spasmodic contractions of the abdominal muscles, and hernia may be 
thus produced. Sometimes convulsions occur, or the patient may 
appear depressed and disposed to heavy sleep during the intervals of 
cough ; a condition even more dangerous than that of convulsions. 
Great prostration may supervene, with loss of appetite, failure of 
nutrition, and death from exhaustion. 

Stage of decline and convalescence. If, however, no serious com- 
plications disturb the course of the disease, after a period of two to six 
weeks, or more, the convulsive stage shows signs of amelioration. The 
paroxysms become less frequent, of shorter duration, and marked by 
diminishing severity. Little by little the whoop ceases to be audible, 
and the catarrhal symptoms remain most prominent. Expectoration 
becomes muco-purulent ; the stomach becomes more retentive of its 
contents ; appetite, digestion, and nutrition improve, and the patient 
resumes his usual health after a period of variable duration. Often, 
after apparent recovery, paroxysms of spasm may be renewed, as the 
consequence of slight disturbances of digestion or of relapsing catarrhal 
conditions in the respiratory organs. Children of a nervous tempera- 
ment may thus appear to be experiencing relapses of whooping-cough, 



246 PARASITIC AND INFECTIVE DISEASES. 

which, however, are not such, but are only manifestations of a nervous 
habit that has become partially engrafted upon the original constitu- 
tion. 

Complications. The most frequent complications are the various 
inflammations of the respiratory organs. These may be recognized by 
the ordinary symptoms of laryngitis, bronchitis, and the different forms 
of pneumonia. Pleurisy with effusion occasionally occurs. The air 
vesicles of the lungs may become ruptured during the paroxysm of 
the cough, producing emphysema of the whole body. The accident is 
generally fatal, but fortunately is of rare occurrence. A more common 
incident is bronchial dilatation. Ulceration and laceration about the 
frenum of the tongue are sometimes observed as a consequence of spas- 
modic protrusion of that organ against the lower incisor teeth. A 
catarrhal condition of the stomach and of the intestines is not uncom- 
mon. Diarrhoea may sometimes occur, but the bowels often remain 
constipated. Severe and obstinate vomiting, especially during the 
later stage of the disease, is not always the result of gastric dis- 
order, but may be a symptom of meningitis. This is usually of the 
tubercular species, and is one of the manifestations of tuberculosis 
which not infrequently follow as sequelae of whooping-cough. Other 
infective diseases often follow or precede whooping-cough. Occasion- 
ally cerebral hemorrhage is witnessed. 

Diagnosis. During the catarrhal stage of the disease, whooping- 
cough can scarcely be distinguished from other catarrhal affections of 
the respiratory organs. But the first characteristic whoop will suffice 
to decide the diagnosis. Sometimes, however, that symptom may be 
absent for a time, but the spasmodic and suffocative character of the 
paroxysms, the tendency to vomiting, and the expectoration of viscid 
mucus, are sufficient to indicate the nature of the disease, especially if 
it prevail epidemically in the neighborhood. Influenza and the coryzal 
stage of measles sometimes resemble the later portion of the catarrhal 
stage of whooping-cough, but the progress of those diseases will soon 
remove all doubt. Capillary bronchitis occurring in rickety children 
is sometimes characterized by a spasmodic cough, but in such cases 
auscultation reveals the signs and symptoms of bronchitis, which are 
absent in uncomplicated whooping-cough. The character of the expec- 
toration differs widely in the two diseases. Certain cases of tuberculosis, 
involving the bronchial glands and the lungs themselves, are sometimes 
accompanied by a spasmodic cough, with duskiness of the face, which 
may suggest the paroxysms of whooping-cough, but in all these cases 
the characteristic whoop is very imperfectly imitated. 

Pathological Anatomy. The morbid changes that are discovered 
after death from whooping-cough are those that characterize the com- 
plications which have induced a fatal termination. Various discoverers 
have endeavored to trace a connection between the disease and certain 
changes involving the meninges of the brain, the medulla oblongata, 
the pneumogastric nerves, or the peri-bronchial glauds .; but there is 
no uniformity of concurrence between the lesions of these organs and 
the symptoms of the disease. 

Etiology. Recently the attention of observers has been attracted 



WHOOPING-COUGH — PERTUSSIS. 247 

by the presence of various bacteria in the bronchial mucus. These 
parasites have been isolated by cultivation, and have communicated to 
rabbits and dogs a catarrhal disease of the respiratory passages, with 
cough, and suffusion of the eyes. These experiments have led to the 
belief that the active agent of the contagion is of bacterial origin. 

The various atmospheric conditions that favor the development of 
ordinary bronchial affections exercise but little influence over the occur- 
rence and propagation of whooping-cough. It, however, occurs more 
frequently in the spring months and in the autumn than during other 
seasons of the year. It attacks children most frequently, because 
adults have generally experienced the disease in their childhood, and 
are thus protected against the disease. Females appear to be more 
subject to it than males. 

The disease is transmitted through the air, and by the medium of 
clothing or other objects that have been in contact with the patient. 
The contagion is probably communicable from the beginning of the 
catarrhal stage until a late period in the stage of decline. 

Prognosis. The uncomplicated disease usually terminates in re- 
covery. Different epidemics, however, vary greatly in the severity 
and in the fatality of the disease, by reason of the complications which 
characterize their course. Early infancy and childhood predispose to a 
fatal termination. According to English statistics no disease is more 
fatal among children in the first year of life. Sixty-eight per cent, of 
all deaths caused by it occur before the end of the second year. After 
the fifth year the mortality is only six per cent. 

Treatment. There is no specific remedy for whooping-cough. The 
indications for treatment are : 1. To relieve the catarrhal symptoms. 
2. To lessen the paroxysmal severity of the cough. 3. To overcome 
the complications that may arise during the course of the disease. 

Catarrhal stage. During this period the cough may be treated like 
any simple bronchial catarrh. Unfortunately, however, it does not 
yield to such treatment, and this fact may suggest a suspicion regarding 
the real nature of the disease. At first a simple mixture containing 
camphorated tincture of opium, syrup of ipecac, solution of the acetate 
ammonium, and glycerin, may be given as required. With the appear- 
ance of a spasmodic tendency in the paroxysms of cough, belladonna in 
appropriate doses may be added to the mixture. 

Spasmodic stage. Depressing agents should be rejected during this 
stage. By the older physicians stimulating emetics, such as sulphate 
of copper, Turpeth mineral, small doses of ipecac, and powdered alum 
were considered of great value in cases that were characterized by suf- 
focative symptoms. Opium must be used with great caution, especially 
in the treatment of very young children. Belladonna and hyoscyamus 
are the most useful anti-spasmodics of vegetable origin. These prepa- 
rations may be given in frequent doses, until moderate physiological 
symptoms of their effect are produced. Brown- Sequard expresses the 
belief that by the watchful administration of atropine for three days, 
in quantities sufficient to produce a moderate efflorescence upon the 
surface of the skin, the paroxysmal stage of whooping-cough may be 
abruptly terminated. Other experimenters are less sanguine. Of other 



2i8 PARASITIC AND INFECTIVE DISEASES. 

anti-spasmodic remedies the most valuable are hydrocyanic acid, the bro- 
mides, chloral, urethan, compound spirits of ether, and the spirits of 
chloroform. Valerian, quinine, oxide of zinc, tannin, musk, asafoetida, 
sulphur, caffeine, cochineal, carbonate of iron, ergot, nitrate of silver, 
nitric acid, alcohol, and innumerable other remedies have been used 
and lauded by many generations of physicians. Antipyrine, phenace- 
tine, acetanilide, and exalgine are now under trial. Various methods 
of treatment by inhalation have been advocated, from the fumes of gas- 
house lime to the latest methods of contaminating the air of the house 
with preparations of carbolic and cresylic acids. Oil of eucalyptus is 
not without some slight value. It may be rubbed upon the body of 
the patient, and a sponge saturated with the liquid may be placed 
under the pillow at night. Vaccination of un vaccinated infants during 
the period of decline sometimes appears to hasten convalescence, but 
generally it produces no marked influence upon the course of the dis- 
ease. Great prostration resulting from excessive severity and unusual 
prolongation of the disease may be favorably combated by a change of 
residence, even within the limits of the same town or city. 

The recognition of the infective character of whooping-cough has 
been followed by attempts to treat the disease by antiseptic methods. 
In accordance with this view, it has been recommended to syringe the 
nostrils and to mop the pharynx with weak solutions of salicylic acid, 
or boric acid, or with a four per cent, solution of cocaine. Corrosive 
sublimate has also been employed for the same purpose, but this is too 
dangerous a drug for such a purpose. 

The strength of the patient must be carefully sustained by an abun- 
dant and digestible diet, in which milk and eggs, and the various pre- 
pared foods that are furnished for young children, should occupy the 
principal place. Warm clothing and uniform temperature, with suffi- 
cient ventilation, must be provided. During convalescence daily exer- 
cise in the open air, in favorable weather, will exercise a salutary 
influence. 

Complications must be treated as they occur. 



CHAPTER XXII. 

BREAK-BONE FEVER— DENGUE. 

Dengue is an epidemic, infective fever characterized by cutaneous 
eruptions, intense articular and muscular pain, intermission, and 
relapse, terminating in convalescence at the expiration of about one 
week. It is a disease that prevails epidemically in tropical countries, 
rarely passing the thirtieth degree of north latitude, yet sometimes pre- 
vailing quite extensively along the shores of the Mediterranean. 

Etiology. Dengue prevails among all classes of the population, 
without regard to age or sex. Locality exercises less influence upon 



BREAK-BONE FEVER — DENGUE. 249 

the prevalence of the disease than the temperature of the atmosphere. 
In elevated regions of the tropics, for this reason, it prevails less com- 
monly than upon heated plains near the level of the sea. It is un- 
doubtedly dependent upon a contagion that is transmissible from person 
to person. Hence the occurrence of the disease may be traced along 
the routes of travel and navigation in and from the lands of the tropics. 
Like the contagion of influenza, the contagion of dengue appears to be 
extremely volatile, so that it is diffused with the greatest rapidity 
throughout the entire community, prostrating almost simultaneously the 
inhabitants in the centres of population. 

Symptoms. The course of dengue is characterized by four distinct 
periods : 1. The period of invasion and transient eruption. 2. The 
period of intermission. 3. Relapse and characteristic eruption. 4. 
Decline and convalescence. 

Invasion. After exposure there is a period of incubation, continuing 
from twelve to twenty-four hours, during which there is sometimes a 
feeling of general disorder ; but usually the invasion of the disease is 
abrupt. The patient is attacked by severe pain in the joints, muscles, 
and nerves, accompanied by a fever that rapidly rises to 102° F., or 
even higher. The head aches ; the whole body is racked with pain ; 
the face swells, and becomes red ; the whole surface of the body burns 
with heat. The tongue is covered with a white coat, and is red at the 
tip and edges ; there is thirst, nausea, sometimes vomiting, constipa- 
tion, or occasional diarrhoea. The urine is generally scanty and high 
colored, but sometimes it is abundant and limpid. In the majority of 
patients the entire surface of the body and the face are covered by a 
diffuse scarlet rash, called by the English physicians in India the initial 
rash. It sometimes occurs in separate patches, resembling the eruption 
of urticaria. Its duration is usually about five or six hours, hardly 
ever continuing so long as twenty-four hours. It then disappears 
without desquamation. 

Period of intermission or remission. At the end of about forty- 
eight hours, or, in rare cases, after a period of five or six days, the fever 
subsides. The painful phenomena of the disease also cease, and often 
a critical perspiration, diarrhoea, or epistaxis may be observed. The 
fever in many instances disappears entirely ; but in others the tempera- 
ture remains above the normal point, and the patient continues in a 
state of considerable prostration. This period of intermission or remis- 
sion continues from one to three days. 

Period of relapse. This phase of the disease is characterized by the 
special eruption called by the Indian physicians the terminal rash. The 
eruption resembles the eruption of measles, scarlet fever, and urticaria. 
It consists of minute papules that are sometimes elevated above the level 
of the skin, accompanied by intense itching. Among these papules a 
number of vesicles, pustules, or bullae are sometimes visible. It com- 
mences usually upon the hands and feet, which become slightly tumefied, 
and extends gradually over the whole body. It continues from one to 
three days. It may be accompanied by fever, though frequently that 
symptom is absent. Sometimes there is a renewal of pain in the 
joints. 



LBASITIC AHD INFECTIVE DISEASES. 

Period of decline. As the eruption disappears the febrile symptoms 
*k so ade, lee uamation follows, as in scarlet fever or in measles. 

The exfoliation of the epidermis occurs in the form of minute, dust-like 
scales, as in measles, or it may peel off in considerable flakes and scales 
rlet fever. This process is frequently accompanied bv con- 
siderable itching. Con vale- :. x ia liable to be considerably prolonged, 
and is often marked by persistent pains in the joints: cutaneous abscesses 
and furuncles sometimes make their appearance. These sequelae of the 
disease not unfrequently defer indefinitely the period of complete 
recovery. Relapses of the fever are also not unfrequent. 

Pr: ;nose Dengu t. ever fatal. The disease is to be 

dreaded, not for its mortality, but for its painful character, and for the 
prolonged valetudinarianism that follows in its wake. 

Diagnosis. The fever of dengue resembles in many particulars the 
other infective fevers that are encountered in warm climates. It must 
be distinguished from mild forms of yellow fever by its relapse, and by 
the eruptions which are absent in yellow fever. The same absence of 
eruption marks the fevers of malarial regions, i? * may 

be distinguished from dengue by the absence of eruption and by the 
discovery of spirilla in the blood of the patient. From influen a 
may be distinguished by the intermission of the fever, and by the char- 
acteristic eruptions. From scarlet fever, dengue may be distinguished 
by the course and remission of the fever, by the absence of sore-throat, 
and by the" concurrence of articular pains with the period of eruption, 
whereas the pains of scarlatinal rheumatism succeed the period of 
eruption in scarlet fever. Measles sometimes resembles dengue, espe- 
cially when that disease is accompanied by redness of the conjunctivae 

- iffusion of thr eyes; but the absence of bronchitis, and the com 

the disease are sufficient to distinguish dengue from measles. S lUpox 
could only be suspected during the invasion of dengue, but the difference 
in the character of the eruptions soon suffices to distinguish thr 

In like manner only a superficial examination could lead to 
confusion between dengue and erysi> 

rheumatism might be mistaken for dengue during the period 
of fever and articular pain : but the course of the fever, and the con- 
current eruption suffice to distinguish dengue from acute rheumatism : 
and from the pain of chronic rl . the articular pains that occur 

during the convalescence after dengue may be distinguished by reference 
to the character of the initial fever and eruption. 

atmext. At the commencement of the fever a mercurial 
cathartic and an efficient emetic are said to afford great relief to the 
headache and pain thai singly characterize the onset of the 

disea- ter this evacuation the patient may be treated during the 

febrile period with antipyrine or phenacetine until the interm> 

- place. During that interval, quinine has been used in large 
doses with a view to the prevention of relapse. The utility of this 
remedy is in proportion to the concurrence of malaria with the con- 
tagion of dengue. Cool baths, and ice-caps applied to the head are 
useful if the fever is excessive and the headache Hypodermic 
injections of morphine and atropine form the most efficient means for 



RELAPSING FEVER — FEBRIS RECURRENT. 251 

the relief of pain. Chloroform liniment may be applied to the painful 
joints. During the period of convalescence, iron, quinine, nux vomica, 
and other vegetable bitters will be found useful. Change of climate is 
one of the most efficient means of restoration in cases that are char- 
acterized by chronic debility. 






CHAPTEE XXIII. 

RELAPSING FEVER— FEBRIS RECURRENS. 

Under conditions of starvation and misery similar to those which 
favor the explosion of typhus fever, a kindred form of epidemic and 
infective fever has been observed, particularly in Great Britain and in 
the north of Europe, commencing with headache, chills, nausea, and 
vomiting. The temperature and the pulse soon rise and increase in 
frequency. The tongue is coated with a thin white fur that may dry 
up and become brown as the disease progresses. There is no diarrhoea 
nor any characteristic eruption upon the skin. The liver and the 
spleen are usually enlarged, and jaundice may appear. Notwithstanding 
considerable nervous excitement and prostration, the mind usually re- 
mains clear. After the expiration of six or seven days, there is copious 
perspiration and rapid fall of temperature to the normal or subnormal 
point. During the second week, the patient remains free from fever ; 
but, about the fourteenth day, a second paroxysm is developed with a 
return of all the original symptoms, At the end of five or six days a 
second intermission is manifested which may pass into convalescence, or 
may be succeeded by subsequent paroxysms similar to those that have 
previously appeared. Unlike certain other contagious fevers, its occur- 
rence does not protect against subsequent attacks, so that the same 
patients may experience the fever more than once during the same 
epidemic. 

Symptoms and Description of the Disease. The length of the 
period of incubation after exposure to infection, is exceedingly variable. 
The fever sometimes commences within a few hours after exposure ; in 
other instances no definite time of infection can be observed ; in others 
it is only after the expiration of one or two weeks that the fever appears. 
Its onset is usually quite sudden, commencing like an intermittent fever 
with a violent headache and a severe chill. Dizziness and nervous 
prostration soon overcome the patient. The duration of the initial chill 
is quite variable. It may continue for a few minutes only, or for a 
number of hours. It is followed by great elevation of temperature, 
accompanied by intense headache and pain in the loins. (Fig. 84.) The 
temperature rises to 105°, 106°, or even 107° F. Sometimes the tem- 
perature rises higher each successive day, with slight morning remis- 
sions, closely simulating the invasion of typhoid fever. During this 
progressive increase, all the symptoms of the disease are progressively 



252 PARASITIC AND INFECTIVE DISEASES. 

intensified. The pulse rises above 100, and raav even reach 150 or 
160 beats. Respiration is accelerated, frequently reaching 40 or 50 per 
minute, although nothing more serious than a slight bronchial catarrh 
may involve the respiratory organs. During the daily oscillations of 
the fever, a little perspiration may appear : occasionally there is a sen- 
sation of slight chilliness. After three or four days, the tongue becomes 
dry and brown : thirst is excessive ; nausea and vomiting are frequently 
observed. The evacuations of the stomach are slimy and bilious, and 
may occasionally contain altered blood, presenting the appearance of 
coffee-ground sediment. The bowels are constipated: jaundice makes 
its appearance ; the urine is highly charged with biliary pigments ; but 
the fecal discharges retain their bilious color, showing that the common 
bile-duct is not completely closed. The liver and the spleen are con- 
siderably enlarged and painful on pressure, giving occasion to uneasiness 
and suffering in the epigastric and hypochondriac regions. The patient 
continues restless and sleepless during the febrile paroxysm, though 
delirium is usuallv absent. 



Pie. B4. 



:r5S555S5SR 



5F51B551 !! iHISIi Mill! 

\u i'tiinwmwmm u laaaaiif 

'■Il'fc /l ■■■■ ' ■ ■■■■»- IHllflll 

IIHHHJilillll lllllllllll 
IFillilllilMMIilHEI 11131 

iiilllilliiiiiiiilHIHrjSil! 
pHiiilliniiiiiiliiiHIiliii 



Temperature in relapsing fever. | Wcxdeblich.) 

In this condition the patient remains for about one week. The 
paroxysm then terminates abruptly by crisis. In a few hours the pulse 
and the temperature resume their normal course : pain ceases : the skin 
becomes moist and copious perspiration may take place. Sometimes 
there is diarrhoea, or a copious discharge of urine, or even some form 
of hemorrhagic incident. With the exception of a certain degree of 
debility, the patient appears to be quite recovered. About fourteen 
days after the original attack a second paroxysm commences. Its 
symptoms and its course are like those of the first paroxysm, but its 

After three or four days a second inter- 



duration is not as great 



RELAPSING FEVER — FEBRIS RECURRENS. 253 

mission takes place, which, like the first, may be followed by a third 
paroxysm. Sometimes there may be four or five, or even a larger 
number of successive paroxysms. Each paroxysm is ordinarily of 
shorter duration than the preceding, and the length of each inter- 
mission corresponds very closely with the duration of the previous 
paroxysm. 

It has been said that relapsing fever presents no characteristic erup- 
tion upon the skin, but this does not negative the fact that during its 
course various eruptions, such as sudamina and the vesicles of herpes, 
may appear as the paroxysms approach their culmination. The skin 
frequently exhibits an increased vascularity ; there is, in about one- 
quarter of the cases, an icteric discoloration of the integument. Some- 
times petechial spots are displayed in cases that are characterized by a 
hemorrhage from the mucous surfaces. 

The quantity of urine is not usually diminished. It is very highly 
colored, and during the febrile paroxysm it contains a large increase of 
urea, During the intermissions the urine diminishes in quantity, and 
its nitrogenous constituents are decreased. Each successive paroxysm 
of the fever is marked by a renewal of polyuria and an increased elim- 
ination of nitrogen. This increased discharge of urine, coincident with 
each febrile paroxysm, is one of the most characteristic symptoms of 
relapsing fever. 

Symptoms connected with the nervous system present nothing charac- 
teristic. There is less nervous exhaustion than in typhus fever ; slight 
delirium, insomnia, occasional convulsions, and sometimes a tendency 
to collapse at the crisis of the fever, are the most prominent features. 
Articular pains are not infrequent, but these are not associated with 
swelling or redness such as are observed in rheumatism. 

Complications. Bronchial catarrh is not infrequent. Pneumonia 
is occasionally observed. Hemorrhages from the different mucous 
membranes of the body sometimes occur near, or at, the close of a 
paroxysm. Transitory paralysis has been observed in the extremities 
during or after a febrile paroxysm. An inflammation of the retina 
sometimes follows the disease, usually after an interval of several weeks 
or months. It is ordinarily limited to one eye, particularly the right 
eye, and rarely produces complete destruction of vision. Diarrhoea 
sometimes occurs as a critical discharge. During the remission of the 
fever it may be accompanied by intestinal hemorrhage. Erysipelas 
is often observed during convalesence, and it sometimes results fatally. 
Dropsical symptoms frequently follow the fever as a consequence of 
weakness of the heart and impoverishment of the blood. 

Diagnosis. Relapsing fever must be distinguished: 1. From bilious 
fever, by the rapid rise of temperature, exceeding what is observed in 
acute gastro-enteric catarrh. 2. From smallpox it may be distinguished 
by the absence of eruption on the third day. 3. From typhus fever, 
with which relapsing fever was long confounded, it may be distinguished 
by the more abrupt and violent onset ; by the absence of the stupor and 
early delirium which are common in typhus fever ; and also by the absence 
of eruptions and by the presence of jaundice. It may also be dis- 
tinguished from typhus fever by the critical intermission of the fever, 



25i PARASITIC AXIi INFECTIVE DISEASES. 

and by its relapsing course. It is only when relapsing fever becomes 
complicated with unusual cerebral disturbances and a typhoid condition, 
that it can be mistaken for typhus fever. 4. From typhoid ~ 
relapsing fever may be distinguished by its abrupt commencement : by 
the rapid elevation of temperature : by the absence of eruption and 
diarrhoea ; by the presence of jaundice : and by the critical inter- 
mission. The abdominal symptoms of typhoid fever, such as tympa- 
nites, diarrhcea, and swelling or ulceration of P oyer's patches, are absent 
in relapsing fever. 5. From malarial fever* relapsing fever may be 
distinguished by the absence of remissions and by the greater length 
of the paroxysms and intermissions. Relapsing fever may also occur 
in regions where malarial fevers are unknown, and. unlike those fevers, 
it is communicable from person to person. 6. Yellow fever differs 
from relapsing fever by the fact that it occurs for the most part in 
tropical climates, or as an imported exotic into temperate regions. It 
is always marked by jaundice of a deeper hue than is apparent in 
relapsing fever. The so-called black vomit, that is of such frequent 
occurrence in yellow fever, is rarely observed in relapsing fever. 
Yellow fever, moreover, presents but one paroxysm, and is far more 
fatal than relapsing fever. 

Prognosis. The duration of relapsing fever rarely exceeds three 
weeks. Its first paroxysm is the most dangerous. The mortality of 
the disease is greater among males than among females, among aged 
people than among children and young people. Below thirty years of 
age the mortality scarcely exceeds two per cent. : above that age the 
mortality is higher. In Great Britain the average mortality is not far 
from four per cent. ; but among the famine-stricken peasants of India 
it may reach twenty per cent. Hemorrhagic and typhoid forms of the 
disease exhibit a mortality of sixty per cent, or more. 

Pathological Anatomy. There are no characteristic changes in 
the majority of uncomplicated cases. Emaciation is considerable. 
There may be slight injection of the mucous lining of the stomach and 
intestines, but no marked alteration of Peyer's patches. The liver is 
enlarged, but nothing can be found to explain the jaundice that exists 
in about one-fourth of the cases. The spleen is greatly enlarged, and 
may occasionally be ruptured, with an effusion of blood into the perito- 
neum. The kidneys frequently present the characteristics of slight 
catarrhal nephritis ; and evidences of hemorrhage, or even of suppu- 
ration, may be occasionally observed. The blood is usually liquid and 
dark in color, and may be loosely clotted in the heart and large veins. 
With the exception of slight catarrhal bronchitis no other characteristic 
changes have been observed. 

ETIOLOGY. The connection of relapsing fever with poverty, famine, 
and social misery has already been mentioned. Age. sex, nationality, 
occupation, and climatic influences exercise little influence over the 
prevalence of the disease. It is dependent upon a communicable poison 
that is transmissible from person to person. This poison owes its ac- 
tivity to the presence of a microorganism that was discovered by Ober- 
meier. in 1873. This microscopical bacterium belongs to the class 
spiro-bcteteria, and is named sptrochozte Ohermeieri. This spiro-bacte- 



RELAPSIXG FEVER — FERRIS RECL'KREXS. 255 

rium, or spirillum (Fig. 85), is a delicate, colorless, spiral filament, 
one-five-hundredth to one-fifteen-hundredth of an inch in length. The 
parasites are only found in the blood, where they make their appearance 
during the paroxysms of the fever, disappearing during the intermis- 
sion, and reappearing with the relapse. They have been cultivated 
outside of the body, and the fever has been communicated to healthy 
persons by inoculation with infected blood. 

Fig. 85. 




Spirillum from the blood in a case of relapsing fever. X 700. (Koch.) 

Treatment. At the outset of the fever the bowels should be gently 
evacuated with a mercurial cathartic, and, as the temperature rises, 
cool baths and cooling lotions may be employed as frequently as may 
be consistent with the comfort of the patient. Antipyrine or phenace- 
tine may be administered when the temperature is high, if perspiration 
be not already excessive. Vomiting may be controlled by the use of 
ice and by the administration of small doses (one-thirtieth of a grain) 
of morphia every half-hour. With this may be given drop doses of 
dilute hydrocyanic acid. Severe muscular pain, restlessness, or insom- 
nia, may be relieved by hypodermic injections of morphia and atropia. 
Diuretics are seldom needed, since the urine is usually increased in 
quantity by the fever itself. Light diet and an abundance of cold 
water may be freely allowed. Much relief at the time of crisis may be 
obtained by frequently wiping away the perspiration which often satu- 
rates the clothing. A tendency to collapse must be opposed by the 
judicious use of stimulants, and by the administration of camphor, cap- 
sicum, nux vomica, and ammonia. During the intermission of the fever 
the patient should be prevented from active exercise or exposure of any 
kind. No remedies have been found that can prevent the relapse, or 
that antagonize the contagion of the fever. After the establishment of 
convalescence the recovery of the patient may be aided by tonic doses 
of iron, quinine, arsenic, strychnia, or the mineral acids. Sequelae, 
such as sometimes affect the eyes, must be treated as they occur. 



256 PARASITIC AND INFECTIVE DISEASES. 



CHAPTER XXIV. 

CHOLERA— CHOLERA ASIATICA. 

Cholera is an acute, epidemic, infective disease that is characterized 
by violent vomiting, purging, collapse, and death in about fifty per 
cent, of the fully developed cases. It is a disease that is permanently 
endemic in India, where its ravages have been recorded from time 
immemorial. From time to time its tendency to diffusion becomes 
aggravated. Emerging from its Asiatic source it extends along the 
lines of travel in every direction, becoming pandemic and invading all 
parts of the world. The first great epidemic of which we have any 
certain information was initiated in the year 1817. Slowly progressing 
in accordance with the moderate rate of travel and the difficulties of 
international communication that then existed, it reached the borders 
of Europe in 1829. During the seven or eight following years it trav- 
ersed the countries of the European continent and America. Since 
that date the disease has again invaded Europe and America a number 
of times, though it has never exhibited the same pandemic virulence 
that characterized its first invasion. 

Symptoms or the Disease. The period of incubation is of variable 
duration. According to certain observers it may be as brief as twelve 
hours, according to others it may continue for three or four weeks. It 
is generally less than a week. The course of the disease may be studied 
in three successive stages. 

1. The stage of invasion. During this period the patient complains 
of general ill-feeling, with uneasiness in the epigastric region, lassitude, 
and nervous prostration. There is loss of appetite, rumbling in the 
bowels, and slight diarrhoea, which usually begins in the night with 
copious watery, yellowish stools of a bilious character, sometimes slightly 
colored with blood. They are discharged without pain, very much like 
the evacuation of an intestinal injection. There is no fever, the tongue 
is broad and covered with a thin white fur. As this diarrhoea con- 
tinues the patient may become constrained to remain in bed. but there 
is nothing alarming in the symptoms, and often they may subside, and 
apparent convalescence may be established. But after a few hours, or 
three or fonr days, the full development of cholera takes place. This 
transition most frequently occurs during the night. The bowels are 
most copiously evacuated, and the stools assume the characteristic ap- 
pearance of rice-water discharges. There is intense thirst, nausea. 
and profuse vomiting, sometimes accompanied by extreme pain. The 
tongue is large, moist and covered with white fur. The abdomen col- 
lapses, and pressure with the hand causes gurgling throughout the 
intestinal tract. The discharge of urine ceases. The patient manifests 
signs of intense prostration. The pulse is small and frequent, the ex- 
tremities grow cold, the whole body appears wonderfully emaciated, the 



CHOLERA ASIATICA. 257 

face becomes thin and anxious. Violent cramps commence in the 
calves of the legs, and extend into other muscles of the body, and the 
algid stage of the disease is developed. The stage of invasion may 
continue from half an hour to one or two days, and in favorable cases 
may terminate in convalescence without the appearance of the successive 
stages of the fully developed disease. 

2. The algid stage. In certain cases this stage of the disease ap- 
pears almost immediately, but it is usually preceded by well-marked 
symptoms of the period of invasion, during which the patient sinks 
gradually into the second degree of the disease. Vomiting and purging 
become less copious and frequent, or sometimes cease altogether. The 
head aches, and there is a sensation of humming in the ears. The 
voice becomes hoarse, feeble, and finally reduced to a mere whisper. 
An unutterable feeling of agony is experienced in the epigastric region. 
The muscles are the seat of painful cramps, there is continual nausea 
and effort to vomit. The eyes sink in their sockets, and are surrounded 
by broad, dark rings that indicate exhaustion. The nose becomes 
pointed and cold, the cheeks sink between the jaws, the whole surface 
of the body becomes cyanosed. Patches of ecchymosis appear upon 
the surface of the body. Points of incipient gangrene sometimes appear 
over bony prominences that are subjected to pressure. The extremities 
become icy cold. The fingers shrivel like those of a corpse ; even the 
breath seems cold, though the patient complains piteously of burning 
heat within the body. The conjunctiva dries like that of a patient in 
an advanced stage of typhoid fever. The movements of the heart 
become progressively weaker. The pulse disappears, respiration is 
frequent, shallow, and unsatisfactory. The muscles become flaccid, 
the skin loses its elasticity, remaining in folds like wet chamois-skin 
when pinched between the thumb and finger. The patient may be 
either restless, tossing about and striving to rise from his bed, or he 
may manifest complete apathy and indifference to his condition. The 
senses fail, and the patient dies in a state of terminal coma. The dura- 
tion of the algid stage may vary from a few hours to two or three days. 
Recovery takes place in only twenty-five per cent, of the cases. 

8. The stage of reaction and convalescence. The process of reaction 
may be either regular or irregular, rapid or slow, simple or complicated. 
In favorable cases convalescence proceeds regularly by the gradual dis- 
appearance of morbid symptoms, and the return of circulation, respira- 
tion, and the production of heat, to their normal standard. Vomiting 
ceases, the natural function of the bowels returns, the kidneys again 
become active, appetite reappears, and often in less than twenty-four 
hours the patient is completely convalescent. 

But in many instances the return to health is interrupted by imper- 
fect efforts toward the restoration of normal function throughout the 
body, followed by relapses of greater or less severity. The patient may 
become delirious, and a typhoid condition may be established. Though 
the symptoms of algidity have disappeared, there is intense prostration. 
The circulation is exceedingly feeble, the body remains cool, the urine 
is scanty, and gastro-intestinal irritation persists for a considerable 
period of time. Convalescence is very slowly established. 

17 



258 PARASITIC AXD INFECTIVE DISEASES. 

In certain other cases the period of reaction is marked by a consider- 
able febrile movement. All the phenomena of fever are present. Vom- 
iting generally ceases, but there is often a persistent diarrhoea. The 
urine may be suppressed, or, if it is secreted, it may be retained in the 
bladder. After eight or ten days the patient becomes comatose and 
dies. 

Varieties of the disease. The prodrvmic diarrhoea that ushers in 
the violent cases of cholera must be considered a mild form of the dis- 
ease. It is excited by the morbific agent, and may suffice to eliminate 
that agent through the alimentary evacuations, without further disturb- 
ance of the system. The opposite degree of infection is exhibited by 
those cases in which the patient is smitten down, apparently in perfect 
health, and dies in a few minutes, perhaps without evacuation of the 
stomach or the bowels, which, after death, are found distended by the 
characteristic rice-water stools. In certain instances the heart seems 
to experience the principal effects of infection, and death occurs from 
complete cardiac exhaustion, preceded by disappearance of the pulse 
and paleness of the skin, without muscular spasms or gastro-intestinal 
discharges. 

In other cases, vomiting and purging constitute the most formidable 
symptoms. The surface of the body becomes cold and pale. There is 
rapid emaciation, and death occurs quietly in collapse. 

Again, muscular spasm, involving various groups of muscles through- 
out the body, may constitute the most characteristic symptom. Respi- 
ration is greatly hindered, and there is profuse cyanosis caused by 
spasmodic contraction of the muscular coats of the small arteries. 
Vomiting and purging are occasionally entirely absent. The patient 
is rapidly asphyxiated, and death soon follows. 

Various cutaneous eruptions have been sometimes observed during 
the period of reaction. Pneumonia, bronchitis, laryngeal diphtheria, 
gangrene of the lungs, meningitis, parotitis, boils, and cutaneous ab- 
s. have also been observed as complications of cholera during the 
period of reaction. In certain cases gastro-intestinal catarrh is per- 
sistent; ano?mia, with its accompanying tendency to oedema, may 
become developed. A disposition to muscular cramps, local paralyses 
and muscular atrophy, intellectual enfeeblement and various forms of 
insanity may be sometimes observed ; but. fortunately, they generally 
terminate in recovery. Purulent inflammations of the conjunctiva, 
nasal mucous membranes, and auditory passages, are not uncommon. 
Aural inflammation with subsequent deafness occurs as frequently after 
cholera as after typhoid fever. 

Pathological Anatomy. — The pathological appearances that are 
observed after death varv according to the stage of the disease in which 
the fatal termination occurred. The morbid changes that characterize 
the algid stage are hypereemia of the brain and spinal cord, hypercemia 
and desquamation of epithelium from the mucous coat of the small 
intestine, and a similar desquamation of epithelium in the tubuli 
urinifcri. If life be sufficiently prolonged, there are visible patches 
of ccchymosis in the serous membranes of the body, the pericardium 
and endocardium, pleura, peritoneum, and meninges. There is an evi- 



CHOLERA ASIATICA. 259 

dent desquamation of epithelial cells from all the mucous and serous 
surfaces of the body, together with a copious discharge of serous liquid 
from the capillary vessels. This fluid, rendered turbid by the admix- 
ture of desquamated epithelium, constitutes the rice-water discharges 
from the alimentary canal : mixed with the desquamated endothelial 
cells, it constitutes the viscid exudation that is often found upon the 
serous surfaces of the body. The follicles of the small intestine are 
swelled, and the intestinal wall is infiltrated with small, round cells. 

If death occur during the period of reaction, a great variety of 
pathological changes may be discovered, according to the severity of 
the symptoms and the character of the complications that have been 
predominant. The lower part of the small intsetine is sometimes 
ulcerated, and the large intestine may present the appearances of 
dysenteric inflammation, if life has been considerably prolonged. 

After death there is sometimes a notable rise of temperature through- 
out the tissues of the body, owing to the fact that their death is not 
simultaneous. Spontaneous muscular contractions are sometimes ob- 
served for several hours after respiration and circulation have ceased. 
The limbs may be thus displaced as if the subject were alive. 

Diagnosis. Cholera nostras closely resembles Asiatic cholera in 
everything except its fatality, which is very slight. It is a disease that 
occurs in all countries during hot weather, and should not be mistaken 
for the Asiatic pestilence, unless an exception be made during the epi- 
demic prevalence of the foreign disease. 

Certain cases of acute poisoning present symptoms that somewhat 
resemble the phenomena of cholera ; but with due attention to the 
symptoms as they occur, the infective disease may be excluded, even 
though it be prevailing epidemically at the time. In case of doubt, a 
careful microscopical examination of the rice-water discharges will 
decide the question by determining the presence or absence of the 
spirilla that characterize the contagion of cholera. 

Prognosis. The mortality in cases of fully developed cholera varies 
little from fifty per cent. The symptoms that indicate the probability 
of a fatal result are violent cramps extending to the upper extremi- 
ties, profound collapse, relaxation of the sphincters, retention of the 
stools by reason of intestinal paralysis, a frequent and feeble pulse, 
rapid and irregular respiration, great depression of temperature, con- 
tinued suppression of urine, especially if associated with a tendency to 
somnolence. Delirium, convulsion, and coma are all symptoms of 
impending death. 

The manifestation, during the period of reaction, of a tendem 
relapse into the algid stage is an alarming sign. Pneumonia, diffuse 
suppuration, and gangrene are indications of the worst possible char- 
acter. 

Etiology. Every condition of life that is antagonistic to health 
may be said to favor the invasion of cholera. But the active agent by 
which the disease is produced and transmitted is a microorganism that 
was discovered in the stools of cholera by Professor Koch, of Berlin, 
who studied the disease in Egypt during the year 1884. and there 




260 PARASITIC AXD INFECTIVE DISEASES. 

made this capital discovery. The bacterium discovered bj Koch is 
slightlv curved in shape, somewhat resembling a comma : hence the 
name comma bacillus that has been frequently 
Fi g. B6. employed in describing the parasite. Its 

length is from one-fifth to one-third of the 
diameter of a red blood-corpuscle. Placed 
end to end the comma bacilli resemble spirilla, 
and they are now considered to be a species 
of that genus, spirillum cholera? asiaticce; the 
so-called comma bacilli being merely segments 
of the developed form. These parasites exist 
in the heated waters of stagnant pools in the 
Delta of the Ganges. Taken into the healthy 
stomach, they are generally destroyed by the 
acid gastric juice and by the bile that they 
encounter in the small intestine. But if the 
Spirillum of cholera. secretions of the alimentary canal be modified 

(HALLOPEAr. by indigestion, the parasitic spirilla are de- 

veloped with great rapidity in the intestine, 
and the phenomena of cholera appear. The parasites are found only in 
the contents of the alimentary canal. They do not penetrate the tissues, 
nor find their way into the general circulation. It is therefore neces- 
sarv to suppose that they produce in the intestines a poisonous substance 
that is absorbed and conveyed into the circulation, and that the phe- 
nomena of the disease are the result of its action upon the nervous and 
other tissues of the body. This substance, which belongs to the class 
of toxalbumins. has been actually isolated, and its poisonous qualities 
have been demonstrated by experiment upon the lower animals. It is 
apparently the only active agent by which poisonous effects are pro- 
duced in cholera, and it is probable that it must accumulate to a certain 
extent in the tissues before any symptoms can occur. 

For this reason the disease is not communicated by personal contact 
or through the air. The intestinal dejections, charged with spirilla, 
must find their way into the drinking-water or food before they can 
reach and infect other persons. In this way it is possible to under- 
stand the propagation of the disease through contamination of drinking- 
water by direct mixture with cholera stools, or by their filtration 
through the soil into such sources of supply as are accessible to a given 
population. Xot only in stagnant water, but in moist earth and upon 
articles of clothing that have been dampened by the rice-water dis- 
charges, can the spirilla of cholera multiply themselves. Soiled clothing 
may thus become the vehicle of transmission between a cholera patient 
and other persons who have occasion to handle such clothing. Through 
lack of cleanliness food and drink may become contaminated, and the 
lethal microorganism mav find its wav into a stomach that has been 
sufficiently disordered to furnish a fiivorable locality for the further 
development of the parasite. Thus it happens that, though not com- 
municated by direct personal contact like the contagion of smallpox 
and diphtheria, cholera is diffused by the agency of man himself. 
Thus it happens that the epidemic progress of the disease follows the 



CHOLERA ASIATICA. 261 

lines of travel and commerce, and is spread by the transfer of human 
beings from place to place. Since the spirillum of cholera can only 
flourish in very warm water, it becomes endemic in very warm climates 
only. Since, moreover, its vitality is very easily affected by a multi- 
tude of chemical agents, it can only prevail as an epidemic where the 
conditions of soil and water and climate are such as permit its multi- 
plication. Hence, in northern countries it usually disappears during 
the winter months, or is only propagated under exceptional conditions 
of warmth and moisture in the dwellings of the inhabitants. It 
apparently finds no permanent establishment outside of India, in con- 
sequence of peculiarities of soil and water that interfere with its in- 
definite propagation. 

Treatment. The much-debated subject of public protection against 
cholera through the agency of quarantine, cannot be fully considered 
within the limits of this volume. It is sufficient to mention the impor- 
tance of early information concerning the existence of imported cases 
of the disease in a previously healthy community. As in typhus fever 
and in yellow fever, the sick should be separated from the well ; the 
stools should be thoroughly disinfected with a five per cent, solution of 
carbolic acid, and everything else that has been contaminated by the 
discharges of the patient should be treated in the same manner. Thor- 
ough cleansing of the infected habitation and its contents will speedily 
eradicate the disease, which tends to become endemic in large and ill- 
kept houses that are inhabited by the poor and negligent classes of the 
population. During the prevalence of cholera great caution should 
be observed in all matters pertaining to diet and digestion. Drinking- 
water should be filtered and boiled ; milk and other liquids that are 
liable to contamination should be treated in the same way. Thorough 
cooking of vegetables will also serve to protect against infection through 
their intervention. Every error of digestion should receive immediate 
treatment, since it is through a morbid condition of the gastro-intestinal 
mucous membrane that the infective parasite finds its opportunity for 
multiplication within the alimentary canal. Undue fatigue and mental 
agitation of every form should be avoided, since by these means the sum 
of bodily resistance to infection is diminished. 

The prophylactic treatment of cholera has received considerable 
attention since the brilliant results of Pasteur in the treatment of 
hydrophobia have attracted the attention of investigators. Hypodermic 
injection of an attenuated virus as a means of prophylaxis has been 
employed in Spain, but the method was imperfect, and the results were 
of a nature that did not admit of scientific valuation. Recent experi- 
ments in Pasteur's Institute have indicated the possibility of successful 
treatment by the prophylactic method, but it has not yet been subjected 
to the test of actual experiment upon man. 

It being a fact that the parasitic agent of the contagion of cholera 
exists and multiplies in the intestinal canal, whence its products are 
diffused throughout the body, it follows that the indications for medical 
treatment are: 1. The destruction of the parasitic growth. 2. The 
early evacuation of their products from the body. 3. The antagonism 
of such products through the administration of some equally diffusible 



262 PARASITIC AND INFECTIVE DISEASES. 

substance that will itself be harmless to the tissues. Guided by these 
considerations the great value of calomel in the prodromal diarrhoea, 
and through the early portion of the invasive stage of the disease, is 
explained. It is a matter of common observation that the administra- 
tion of ten grains of calomel, followed by a gentle laxative like castor 
oil, and succeeded by a few doses of bismuth and opium, is sufficient to 
arrest the attack of diarrhoea which otherwise would culminate in 
cholera. With the same object in view, naphthaline has been recom- 
mended in doses of five grains every two, three, or four hours. Since 
the cholera spirillum cannot survive in an acid medium, the employ- 
ment of mineral acids as therapeutical agents has been widely recom- 
mended, especially during the period of indigestion and diarrhoea that 
precedes the explosion of cholera. For this purpose, after evacuation 
of the bowels, the patient may take the following prescription : 

Bl. — Acid, hydrochl. dilut 5j 

Tr. opii deod. % j 

Aquae q. s. ad ^vj. — M. 

S. — Take a teaspoonful in a wineglass of water every hour until the pupils 
begin to contract. Then continue at longer intervals. 

With a view to the destruction of the parasites in the intestine, Can- 
tani has recently recommended the use of large injections of tannic 
acid, dissolved in water at the temperature of the body. Two or three 
quarts of warm water, containing from thirty to ninety grains of tannic 
acid, and from five to fifteen drops of tincture of opium, in each quart, 
should be thrown into the bowels from three to six times in the course 
of twenty-four hours. By this means the accessible portions of the 
intestinal tract are cleansed and disinfected. With the same object in 
view large doses of salol have been recommended for administration by 
the mouth and by injection into the bowels. During the stage of 
vomiting and rice-water discharges, the patient may be permitted to 
swallow small pieces of ice, and may be given the fiftieth of a grain of 
morphine every fifteen or twenty minutes until the pupils begin to 
contract. Mild attacks of the disease may be arrested with ordinary 
preparations of opium and astringents : 

K . — Pulv. opii gr. iv. 

Bismuth, salicylat. gj. — M. 

Div. in chart, no. xii. 

S. — Take one powder every hour. 

Or, 

Be. — Tr. opii deod. 3j. 

Tr. cinchon. co 3 x — M 

S — Take a teaspoonful in ice-water every hour until the pupils begin to 
contract. 

Attempts have been made to repair the immense loss of liquid occa- 
sioned by vomiting and purging, and the consequent thickening of the 
blood, by intra- venous injections of a weak saline solution, but the 
results have not been encouraging. A better effect has been produced 
by hypodermic injection into the loose subcutaneous tissues below the 
clavicles, or between the ribs and the iliac bones, of a tepid solution of 



CHOLERA NOSTRAS, OR EUROPEAN CHOLERA. 263 

sodium chloride and sodium carbonate in sterilized water. The strength 
of the solution should be twenty grains of sodium carbonate and thirty 
grains of sodium chloride in a pint of water. Of this, at least a quart 
may be gradually injected, and, even in the stage of collapse, its use is 
often followed by rapid improvement, which sometimes results in 
recovery. During the algid stage opiates should no longer be admin- 
istered, since they are not absorbed, and their accumulation in the 
stomach may become a source of danger should reaction take place. 
A preferable stimulant is found in a ten per cent, solution of camphor 
in ether, of which ten or fifteen drops may be given in ice-water every 
half or quarter of an hour. Ten drops of the same solution, or of 
ether alone, form a powerful cardiac stimulant when hypodermically 
injected. A one per cent, aqueous solution of alcohol, with three- 
fourths of one per cent, of chloride of sodium, may also be injected 
hypodermically every few minutes, in quantities of two ounces at a 
time, until eight or ten quarts have been thus introduced beneath the 
skin. Hydropathic treatment, with massage and other similar manipu- 
lations, have been recommended with a view to equalization of the 
circulation and the promotion of perspiration. During the stage of reac- 
tion the function of the kidneys should be stimulated by the use of 
warm baths, with dry cups over the loins. For three or four weeks 
after the commencement of convalescence the diet must be carefully 
regulated and limited to articles that are easy of digestion. 



Cholera Nostras or European Cholera occurs during hot weather in 
any part of the world. It is an acute gastro-enteritis that may be 
excited by errors of diet, exposure to chill when heated, and by the 
ordinary causes of gastro-enteric catarrh. It is probably connected 
with bacterial growths in the alimentary canal; and a comma bacillus, 
somewhat resembling that of Asiatic cholera, has been observed in the 
rice-water stools. The disease is characterized by an abrupt invasion, 
vomiting, purging, rice-water stools, muscular spasm in the calves of 
the legs, thighs, and sometimes extending to the abdomen and upper 
extremities. In severe cases the symptoms are very like those of 
Asiatic cholera. An appearance of collapse is not uncommon, but it 
rarely terminates in death, excepting in the case of weakly children or 
of enfeebled old people. The duration of the attack seldom exceeds 
twenty-four or forty-eight hours, though the period of convalescence 
may be long and marked by considerable debility. 

The diagnosis is chiefly determined by the exclusion of Asiatic 
cholera, and the possibility of acute poisoning with corrosive sublimate, 
arsenic, tartar emetic, tainted mussels, meats, fish, custards, ice cream, 
and other substances in which bacterial toxines can be developed. 

The treatment consists, after evacuation of the stomach and bowels 
has been completed, in the administration of opiates, preferably by 
hypodermic injection. A quarter of a grain of sulphate of morphia 
may be thus given every two or three hours until reaction commences. 
If excessive nausea does not prevent, an eighth of a grain of morphia 
with ten grains of subnitrate of bismuth may be given every four hours. 



264 PARASITIC AND INFECTIVE DISEASES. 

The abdomen should be covered with a large linseed-meal poultice into 
which a drachm of chloroform has been stirred. The extremities should 
be kept warm by placing bottles of hot water, wrapped in flannel, in 
the bed. Ice may be given to allay thirst, and brandy also, in tea- 
spoonful doses every ten minutes, till reaction begins. During the 
period of convalescence a milk diet should be enjoined. 



CHAPTER XXY. 

TYPHUS FEVER— TYPHUS EXANTHEMATICDS. 

Like the plague, typhus fever has prevailed endemically and epi- 
demically from the remotest antiquity. Between the two diseases the 
resemblance is so considerable that by the ancient narrators they were 
frequently confounded with one another. Alike dependent upon social 
misery, these twin diseases have followed in the wake of war and pesti- 
lence from time immemorial. But with the increase of prosperity and 
the progress of sanitation both pestilences are receding before the 
advance of civilization. In America typhus fever is unknown except 
as an occasional importation from Europe: and upon the eastern con- 
tinent it is seldom encountered outside of Ireland and Russia. 

Description of the Disease. The fever commences abruptly 
with headache, chills, physical discomfort, and debility, which in a few 
hours are succeeded by high fever. The patient complains of great 
prostration, pain in the head, back, and limbs. The expression of the 
countenance is dull and heavy, the face is flushed and somewhat swelled, 
the eves are red, the pupils are contracted, and the eyelids are thick- 
ened. The temperature soon reaches 104 C or 105° F. : the pulse ranges 
above 100 : the tongue becomes thickly coated : there is thirst and con- 
stipation : there may be cough, and a catarrhal condition of the bron- 
chial and gastro-intestinal mucous membranes. Sleep is uneasy and 
disturbed by dreams. But the intellectual faculties of the patient, 
though somewhat sluggish, are not clouded. Between the third and 
fifth day an eruption appears upon the surface of the body. Sometimes, 
however, the eruption is tardy in its appearance, or may be entirely 
absent. It consists of spots, described by English authors as the 
; * mulberry rash.*' At first they disappear upon pressure, but later in 
the course of the disease they cannot be thus effaced. They resemble 
the eruption of measles, though rather darker in color. They cover 
the body and limbs, but do not often appear upon the face or neck or 
inside of the mouth. Besides these mulberry-colored spots there are 
rose-colored spots that disappear upon pressure, and resemble the simi- 
lar eruption of typhoid and other infective fevers. During the later 
stages of the fever petechial spots make their appearance in cases that 
are marked by great severity. They do not disappear upon pressure, 
are often confluent, dark in color, and may even result in actual sub- 



TYPHUS FEVER — TYPHUS EX ANTHEM ATICUS. 265 

cutaneous hemorrhages. In addition to these eruptions the skin appears 
mottled and dusky from numerous minute extravasations and capillary 
injections throughout the deeper cutaneous layers. 

At the expiration of a week the fever sometimes lessens, the skin 
becomes slightly moist, the mind clears, and convalescence commences. 
But generally the second week is characterized by greater severity in 
all the symptoms. There is less redness of the eyes, but the pupils are 
contracted, and inflammation may attack the internal structures of the 
eyeball. The sense of hearing becomes less acute or is temporarily 
abolished. The sense of smell, in like manner, is lost ; sometimes there 
is epistaxis, especially in the early stages of the fever. The tongue 
becomes dry and brown ; the gums swell ; there is a catarrhal condition 
of the fauces, which are covered with a pasty exudation. There may 
be difficulty in swallowing, thirst is intense, occasionally there is 
nausea and vomiting, and constipation may be replaced by diar- 
rhoea. There is no distention of the abdomen, nor any intestinal 
gurgling. The spleen and the liver are enlarged, the abdominal 
walls give evidence of tenderness on pressure. As the pulse and 
the temperature rise or fall the movements of respiration follow suit. 
There is slight cough, without thoracic dulness or evidence of anything 
more serious than a bronchial catarrh. The pulse, which was full and 
strong at the commencement of the fever, keeps pace with the tempera- 
ture, remaining quite uniformly above 100 beats per minute. 

The temperature, which from the outset of the fever reached 104° or 
105° F., experiences a slight daily remission until the termination of 
the fever, which occurs by crisis about the end of the second week. It 
then falls suddenly and the period of convalescence commences. In 
all cases, and especially in those of a dangerous character, the skin of 
the body of the patient exhales a peculiar, musty odor suggestive of 
putrefaction. These exhalations undoubtedly are charged with the con- 
tagion of the disease. The urine is scanty and high-colored, and, as 
in other fevers, often contains a small quantity of albumin. The 
nervous system manifests grave disturbances ; headache is almost uni- 
versal, but gradually subsides with the course of the fever. The skin, 
especially over the anterior portion of the body, is abnormally sensi- 
tive, the muscles and the joints frequently give evidence of pain if sub- 
jected to pressure or movement. During the first week the intellectual 
faculties are dull and sluggish, and the patient often seems to be half 
asleep. During the second week this torpor passes into a state of stupor 
or coma. Delirium may be present, tonic spasms of the dorsal and cer- 
vical muscles may produce partial opisthotonos ; convulsions sometimes 
occur. Insomnia is of common occurrence. In fatal cases the patient 
may be suddenly smitten down as if by a dose of poison, or if life be 
prolonged, he sinks into a typhoid condition, lying upon the back and 
slipping down from the pillow into the bed, unconscious and insensible, 
the dry and blackened tongue visible in the open mouth, respiration 
slow and feeble, the pulse compressible and often imperceptible, the 
bowels evacuating themselves in the bed, the urine being suppressed, 
the whole body exhaling a corpse-like odor ; death soon closing the 
drama. 



266 PARASITIC AXD INFECTIVE DISEASES. 

Mild forms of the disease, however, are not uncommon. In these 
cases the characteristic symptoms are present, hut are not marked by 
any great degree of severity or danger. 

Abortive forms of the fever are also encountered. These are the 
cases that terminate at the expiration of the first week. 

Sometimes a patient manifests a disinclination to remain in bed. and 
may endeavor to continue his ordinary occupations ; or, if he be placed 
in bed. he is liable to make his escape and to walk about, apparently 
unconscious of nakedness or illness. These cases constitute the 
ambulatory form of typhus fever. In certain epidemics inflammation 
of the parotid gland, or of the large veins in the lower extremities, may 
occur. Unusual and extraordinary hemorrhages may result from a 
scorbutic condition of the patient, and are always indicative of the 
gravest danger. Gangrene may attack the extremities and other parts 
of the body, especially those portions that have been weakened by 
pressure, lack of cleanliness, or local injury. Bedsores, cutaneous 
abscesses, and pyemic accidents may also occur. The organs of 
special sense may thus undergo destruction. 

Pathological Anatomy. The large veins are distended with black 
and liquid blood, which, if clotted, lies in loose and imperfectly coagu- 
lated masses. The mucous membranes of the body exhibit an appear- 
ance of hyperemia or of slight catarrhal inflammation. The liver and 
the spleen are generally enlarged and engorged with blood. The heart 
is soft and pale, its right side distended with blood; its muscular fibres 
exhibit a finely granular degeneration. The lungs are frequently en- 
gorged with blood, and local pneumonia, even gangrene, may sometimes 
be present. If death occur early in the course of the disease, the brain 
and its membranes are congested. At a later period there is ancemia 
and an (edematous condition of the tissues. 

Etiology. It is generally admitted that the contagion of typhus 
fever owes its virulence to the presence of a microorganism, which, 
however, has not yet been identified. The infective substance is contained 
in all the excretions of the patient, and it is transmissible to a very 
short distance through the medium of the atmosphere. For this reason 
healthy persons who enter an ill-ventilated apartment and breathe the 
effluvia run a much greater risk of infection than those who handle the 
bodies of similar patients in the open air. Free dilution of the poison 
soon destroys its activity. Clothing and other articles that have been 
in contact with the sick may become the vehicles of transmission of 
contagion, especially if they be enclosed in tight boxes or other con- 
tainers that do not admit the air. Water and other liquids do not 
serve as vehicles for the contagion. 

Mortality. The degree of fatality depends upon the character of 
the particular epidemic and the special conditions that determine its 
prevalence. Under favorable conditions, in a rural population, the 
mortality may not exceed five or six per cent., but in times of war and 
famine and in the midst of pauperized communities, the mortality may 
rise to fifty or sixty per cent. During the Crimean war. where every- 
thing combined to complete the sum of human misery, in certain 



TYPHUS FEVER — TYPHUS EX AXTHE M A TICUS . 267 

hospitals every inmate died of the fever. The average mortality, 
however, does not exceed fifteen to twenty per cent. 

Diagnosis. Typhus fever must be differentiated : 1. From typhoid ; 
2. From relapsing fever; 3. From the plague; 4. From measles; 
5. From cerebro-spinal meningitis. 

1. From typhoid fever it may be distinguished by the greater duski- 
ness of the countenance ; by the characteristic mulberry rash ; by the 
rapid rise of temperature, which reaches its maximum in a few hours ; 
by the early termination of the fever and its speedy disappearance by 
crisis. During the course of the disease the headache and other pains 
are more frequent than in typhoid fever. Stupor and delirium make 
their appearance at an earlier period and are more common. Abdominal 
symptoms also are less marked than in typhoid fever. The belly is not 
distended, there is no gurgling nor evidence of tenderness in the ileo- 
cecal regions. The bowels are usually constipated ; the liver is larger 
and the spleen smaller than what are observed in typhoid fever. 
Bronchial catarrh is also more frequent and the peculiar odor exhaled 
by the patient is itself diagnostic. 

2. From relapsing fever it may be distinguished by the course of 
the disease without intermission or relapse ; by the mulberry rash, 
which is absent in relapsing fever ; and by the bilious and icteroid 
disturbances which are so frequent in relapsing fever. 

3. Plague and typhus fever have been frequently mistaken for each 
other ; but the rapid course of the plague and the early appearance of 
buboes and carbuncles, together with the absence of delirium, are 
sufficient to distinguish that disease. 

4. Malignant cases of measles not unfrequently resemble typhus 
fever in certain particulars. But the eruption of measles upon the 
face and upon the soft palate ; the presence of coryza ; the normal 
condition of the liver and of the spleen, and the concurrence of ordi- 
nary forms of the disease in other patients, are sufficient to distinguish 
measles. 

5. Cerebrospinal meningitis is characterized by terrible pain in the 
head and spine ; retraction of the neck ; frequent vomiting ; eruption 
of herpes from the second to the fourth day ; and albuminuria. The 
mulberry rash is also absent in the meningeal disease, the course of 
which is usually more violent and rapid than that of typhus fever. 

Prognosis. The earlier cases that occur in the course of an 
epidemic are more fatal than the later. The contagion seems to be 
attenuated by its transmission from patient to patient. Unfavorable 
hygienic conditions, previous states of ill health, complications with 
other diseases, mental depression, discouragement and despondency, 
all combine to render the prognosis unfavorable. In individual cases 
the early manifestation of prostration, contraction of the pupils, irreg- 
ularity and weakness of the heart, continuous delirium, difficult respira- 
tion, involuntary stools, suppression of the urine, unusual discoloration 
of the skin, duskiness of the eruption, the development of a hemor- 
rhagic tendency, excessive pungency of the exhalations, uncommon 
elevation or depression of temperature, with irregularities in the course 



268 PARASITIC AXD INFECTIVE DISEASES. 

of the fever, and the appearance of intercurrent disease, are all alarm- 
ing symptoms indicative of probable dissolution. 

Treatment. The patient must be removed from unhygienic sur- 
roundings, and should be taken from the wretched lodging-houses in 
which the disease usually prevails, and be placed in a thoroughly venti- 
lated hospital pavilion, or under canvas, if the weather will permit such 
free exposure. The utmost cleanliness of person and of bedding must 
be secured. The evacuations of the body must be removed and dis- 
infected as speedily as possible. The diet should consist of milk, gruel, 
and animal broths, which must be given at regular intervals throughout 
the twenty- four hours. The temperature must be reduced by the em- 
ployment of cold beverages, cool sponging, and baths of water at a 
temperature of sixty-five to seventy degrees. An ice-cap upon the head 
and the application of Leiter's coils about the body will be frequently 
of service. The bowels may be evacuated by the use of saline laxatives, 
such as citrate of magnesia or Seidlitz powders. Dilute mineral acids 
in doses of fifteen to thirty drops may be given every three or four 
hours. Great prostration of the nervous system may be treated with 
aromatic spirits of ammonia, with Hoffmann's anodyne, spirits of chloro- 
form, oil of cajuput, and dilute hydrocyanic acid combined with small 
doses of the deodorized tincture of opium. Camphor and musk are 
useful in cases marked by a tendency to failure in the circulation. 
Symptoms of asphyxia require the administration of capsicum and 
strychnine. Constipation of the bowels may be relieved by enemata. 
The bladder should be frequently examined, and the urine must be 
withdrawn by the aid of a catheter if it be retained. During the later 
stages of the disease, alcoholic stimulants may sometimes be administered 
with advantage. Quinine should be postponed until the commencement 
of convalescence, when it and other tonic remedies may be given with 
great advantage. Gangrene of the extremities, bedsores, and other 
complications must be guarded against, and appropriately treated if 
they occur. 



CHAPTER XXVI. 

THE PLAGUE-FESTILENTIA. 

From the remotest antiquity vague narratives of epidemic pestilence 
ravaging the countries of the East, invading the borders of the Medi- 
terranean, and decimating the population of Europe, have come down 
to modern times. Many of these epidemics were undoubtedly identical 
with the plague, but the imperfect observation, or lack of observation 
and medical discrimination, in those early ages, renders it impossible to 
identify the characteristics of all the historical examples that have been 
handed down to us. Few diseases, moreover, present greater variety of 
symptoms than the plague, consequently the historical references to 
such visitations have undoubtedly made certain features more prominent 



THE PLAGUE — PESTILENTIA. 269 

in one generation, and others in another. It is, however, very certain 
that this was one of the principal scourges of early civilization along 
the coasts of the Mediterranean Sea. It was during the Middle Ages, 
after the establishment of greater freedom of intercourse with Asia, that 
the pestilence reached its greatest severity, culminating in the Black 
Death, as was called the great succession of epidemics that ravaged 
Europe during the middle of the fourteenth century, and in the period 
of eight years destroyed the lives of 24,000,000 of the inhabitants of 
that continent. With the progress of civilization and improvement in 
the mode of living that characterizes the present century, the plague 
has become unknown in Europe, and now prevails only at intervals 
within narrow limits in the central regions of Asia. 

Description of the Disease. The onset of the disease is usually 
sudden and is marked by serious disturbance of all the functions. 
There is a feeling of intense prostration, severe headache or vertigo : 
the skin is pale ; the eyes are sunken, sometimes red, with dilated 
pupils ; the voice becomes enfeebled ; the patient staggers as if intoxi- 
cated, and complains of a burning sensation in the nasal passages, 
throat, and stomach, accompanied by nausea, vomiting, and sometimes 
by diarrhoea. After a few hours there is a severe chill, followed by 
high fever, intense headache, and thirst. The tongue is moist and 
covered with a white fur; there is gastro -intestinal pain, and continued 
vomiting. Respiration is accelerated, and the pulse rises above 100 
beats. This condition soon passes into a stfate of profound prostration, 
with delirium deepening into stupor and coma ; the mouth becomes dry 
and filled with sordes ; internal heat increases, while the extremities 
become cold. The pulse is small, feeble, and rapid ; there are obstinate 
vomiting, bronchial catarrh, and hemorrhage from the nose and other 
cavities of the body ; the urine is scanty, and sometimes charged with 
blood. 

After the fever has continued for two or three days, eruptions appear. 
These take the form of buboes in the groins, in the arm-pits, about the 
neck, and elsewhere. Carbuncles also develop upon the body and limbs. 
There is copious perspiration, and the fever exhibits a tendency to 
remission. In fatal cases, petechial spots, bloody wheals, and ecchy- 
motic patches appear upon the skin. Death may occur at any time 
during the course of the disease. If life is prolonged until the remis- 
sion of the fever, which usually occurs from the sixth to the tenth day, 
the buboes or carbuncles suppurate freely, and convalescence commences. 
Recovery is usually very slow in consequence of the numerous compli- 
cations that hinder its course. Numerous abscesses, boils, and other 
evidences of pyaemia are of common occurrence. Dropsy and paralysis 
sometimes appear. 

Pathological Anatomy. The membranes of the brain and of the 
spinal cord sometimes show evidence of ecchymosis. The veins are 
engorged with blood, and the substance of the brain exhibits minute 
extravasations of blood. The serous cavities of the body contain a 
certain amount of serum that is frequently stained with blood. The 
lungs are in a state of hypostatic congestion, the mucous membrane of 
the bronchi often exhibits inflammation ; and in hemorrhagic cases there 



270 PARASITIC AND INFECTIVE DISEASES. 

will be everywhere numerous signs of local hemorrhage. Similar 
evidences of congestion and hemorrhage appear throughout the alimen- 
tary canal as far as the ileo-csecal valve. The large intestine is usually 
healthy. The liver is very greatly enlarged, and the gall-bladder is 
immensely distended with green bile ; the spleen also is enlarged and 
softened : the pancreas is enlarged and sometimes indurated. The 
kidneys are engorged with blood, which sometimes fills the pelvis and 
ureters, and even the bladder. The lymphatic glands are greatly en- 
larged and inflamed. The connective tissue around them becomes 
inflamed, and even gangrenous. Thus are formed the buboes and the 
carbuncles that characterize the disease. The blood is darkly fluid, 
and is rapidly decomposed. 

Etiology. It is in the mountainous regions and elevated plains of 
Central Asia that the plague may be said to be endemic. It prevails in 
temperate climates, and never invades the tropical regions of the earth 
for the reason that a high temperature destroys its contagion. Moderate 
heat and a moist atmosphere apparently favor the propagation of the 
infection. It is during the winter and spring months that the disease 
prevails in its native localities, where it thrives in the moist heat of ill- 
ventilated habitations. Its pandemic prevalence may, however, progress 
throughout the entire year. Chief among the local causes of the dis- 
ease are poverty, filth, famine, and war. Differences of sex, age, tem- 
perament, and profession exert very little influence upon susceptibility 
to the disease. Bodily fatigue, all forms of excess, and previous con- 
ditions of ill health are active among the predisposing causes. 

But the exciting cause of the disease is a definite contagion, the 
nature of which, owing to the obvious difficulties that attend the 
research, has not yet been elucidated. It is probable, however, that 
the contagious matter is a microorganism of bacterial character. This 
contagious matter is contained in all the excretions and effluvia of the 
patient, and may be transmitted either through the air, or by the 
medium of clothing and other articles that have become infected. The 
contagious element is not rapidly diffusible, being probably of a weighty 
character. Consequently the disease spreads less rapidly than cholera, 
though its progress is more rapid than that of typhus fever. It is 
probable that healthy persons are usually infected through the respira- 
tory passages, but it is not certain that the infection may not invade 
the body through other avenues of entrance. The period of incubation 
after exposure varies from a few hours to six or seven days. 

Treatment. There is no antidote to the contagion of the plague. 
Many cases are smitten down and die so promptly that opportunity for 
treatment does not exist. When, however, the disease pursues a more 
deliberate course, its various symptoms must be treated in accordance 
with general principles. The intense fever should be antagonized with 
cold baths and large doses of phenacetine, of which from ten to fifteen 
grains may be given at once, and should be repeated every two or three 
hours. Symptoms of gastro-intestinal irritation should be soothed by 
hypodermic medication with morphine and atropine. Alcoholic stimu- 
lants may also be cautiously administered. The tendency to hemor- 
rhage demands the use of aromatic sulphuric acid and other astringents. 



YELLOW FEVEK — FEBRIS FLAVA. 271 

During the formation of buboes and the development of pyemic inci- 
dents, the treatment resolves itself into that of pyaemia, and must be 
conducted in accordance with the principles of antiseptic surgery. 

In ancient times it was customary to quarantine plague-smitten 
patients by imprisoning them in their houses, where they for the most 
part died without help of any kind. By this mode of treatment the 
virulence of the pestilence was greatly intensified, and its epidemic 
progress was really facilitated. Only when a limited community can 
be thus thoroughly isolated and sacrificed are such stringent measures 
justifiable. The most successful method of limiting the disease consists 
in the removal of infected persons from their homes into temporary 
hospitals or tents, if the weather will permit, where perfect cleanliness 
and ventilation can be continually maintained. Healthy people should 
remove from the infected locality, and should not return until the 
termination of the epidemic If, however, the population has been 
previously infected, such removal may be the means of transmitting 
the disease to distant localities. It is thus that epidemics of the plague 
have become widely extended. The endangered population should, 
therefore, be retained as near home as possible, while every provision 
is made for complete cleansing and disinfection of their habitations. 
But, above all things, the most important is the prevention of the dis- 
ease through measures of public sanitation and judicious quarantine. 
The plague cannot prevail in a cleanly community. Cremation of the 
bodies of the dead should be practised in preference to earth-burial. 



CHAPTER XXVII. 

YELLOW FEVER. FEBRIS FLAVA. 

Yellow fever is an acute, infective, epidemic fever, characterized 
by a paroxysm of invasion, followed by a period of remission that is 
succeeded by a relapse, speedily terminating either in death or in 
decline and convalescence. It is a disease that occurs endemically in 
the tropical seaports of the Gulf of Mexico, the coast of Brazil, and 
the inter-tropical shores of Western Africa. From these localities it 
is diffused epidemically along the lines of ocean travel ; and, during 
the prevalence of warm weather in temperate climates, it may be trans- 
ported to a considerable distance inland from the seaports which have 
been thus invaded. It has thus become known in the southwestern 
parts of Europe, in England, in the maritime seaports of the Atlantic 
States of America, and in the cities of the valley of the Mississippi. 
It is a disease that can only prevail when the temperature of the atmos- 
phere is continuously raised to the level of summer heat ; by the first 
frosts of autumn its epidemic progress is at once arrested. For this 
reason it cannot prevail at any considerable elevation above the level 
of the sea. 



272 PARASITIC AXD INFECTIVE DISEASES. 

Symptoms. The period of incubation after exposure to yellow fever 
is exceedingly variable. It may occupy but a few hours, or it may 
endure for nearly a month. As a general rule it lasts from one to 
four or five days. 

Period of invasion. The disease commences quite abruptly, most 
frequently during the night. It may be ushered in with a brief chill, 
which, however, does not always occur. There is severe headache and 
intense pain in the loins ; sometimes there is vomiting. The fever 
quickly follows, and the temperature in a few hours rises to 104° or 
106° F. Having reached this level on the first or the second day. it 
begins to fall more or less graduallv, often with slight oscillations, until 
the third, fourth, or fifth day, when, in mild cases, the normal tempera- 
ture is reached, and recovery is established. The pulse rises more 
rapidly than the temperature ; at first full and strong, having reached 
its maximum, it begins to lose its volume and force with the decline of 
the fever, reaching the normal figure about the sixth or seventh dav. 
In fatal cases it becomes weak and rapid, even with a falling tempera- 
ture. In mild cases respiration is not affected, but in severe forms of 
the disease respiration may be disturbed by a congested state of the 
lungs, or by the nervous disorder that accompanies the disease. The 
gums are swelled, the mucous membrane of the mouth presents a 
catarrhal appearance : the tongue is at first moist and soft, generally 
broad and swelled, with a thick white fur, while the tip and the edges 
are of a bright-red color : sometimes there is no change in the appear- 
ance of the organ. A tendency to hemorrhage is often preceded by a 
red band occupying the centre of the tongue from its tip to its base. 
As the disease progresses the tongue becomes red and pointed ; in 
hemorrhagic cases it bleeds, and becomes darkly colored. The patient 
is tormented with thirst, which increases with the danger of a fatal 
termination ; its absence is a favorable symptom. 

The occurrence of nausea and vomiting exhibits nothing character- 
istic at the commencement of the fever. After two or three days the 
vomited matter consists, in serious cases, of blood mixed with mucus, 
or a brownish or even a black liquid, constituting what is known as 
the black vomit. The liquid thus ejected resembles an infusion of 
coffee, with an abundant sediment consisting of altered blood corpuscles, 
decomposed haemoglobin, and traces of fibrin. In the worst cases the 
vomited matters may resemble pitch in color and consistence. Recovery 
has never been known in such cases. 

During the period of invasion the boivels are generally constipated. 
but they become relaxed during the later periods of the disease. Ab- 
dominal pain and distention are usually absent, though there may be 
some tenderness on pressure over the epigastrium after the act of 
vomiting. 

The urine is generally less in quantity than during the state of 
health ; in dangerous forms of the disease the quantity is greatly 
reduced, and may be entirely suppressed. In mild cases the color of 
the urine varies but little from that of health : but in severe forms of 
the disease it is acid and high colored, and sometimes deposits a sedi- 



YELLOW FEVER — FEBRIS FLAVA. 273 

ment of urates. Albumin is always present in severe cases. Blood 
may also be present in hemorrhagic cases. 

In mild forms of the disease the skin is warm and moist during the 
febrile stage ; as the temperature falls, abundant perspiration may take 
place with great relief to the patient. In severe forms of the disease 
the occurrence of copious perspiration without improvement in the con- 
dition of the patient is a symptom of very great danger. 

Various cutaneous eruptions are frequently observed during the 
course of the fever, such as miliary vesicles, patches of herpes about 
the mouth, various rose-colored spots scattered here and there, some of 
them resembling mosquito bites, others placed so near together as to 
resemble ecchymoses. Upon the anterior surface of the body, and 
upon the inner surfaces of the limbs, may be sometimes seen pustules, 
bullae, and purple or livid spots of a hemorrhagic character. Ery- 
thematous patches that manifest a tendency to gangrene appear upon 
the scrotum and in the folds of skin most affected by heat and moist- 
ure. In the majority of cases, as the fever declines, about the third 
or fourth day, the surface of the body becomes discolored with the hue 
of jaundice. At the same time the urine assumes a dark-red color, 
and contains the coloring matter of the bile. These elements only 
appear in the blood during the latest stage of the disease. The dis- 
coloration of the skin is therefore originated by an alteration of the 
blood itself, rather than by the passage of bile pigment into the cir- 
culation, an event which only occurs at a period later than the com- 
mencement of jaundice. 

So variable is the intensity and danger of the disease that its course 
exhibits a corresponding difference in severity and prominence of in- 
dividual symptoms. In mild cases there is little to discover besides a 
fever of brief duration, accompanied by the ordinary nervous and 
secretory disturbances that accompany a febrile movement of brief 
duration. In severer cases the brief introductory chill is followed by 
a high fever, with headache, rhachialgia, and pain throughout the limbs 
and joints. The eyes sparkle, the conjunctivae are slightly injected, 
the pupils are dilated, the skin is hot and dry, or slightly moistened 
with perspiration. The pulse is full, strong, and frequent ; respiration 
somewhat accelerated ; nausea and vomiting accompany the onset of 
the fever, and are succeeded by an uneasy sensation at the pit of the 
stomach ; the bowels are usually constipated ; the urine is scanty and 
high colored ; considerable nervous agitation is sometimes exhibited by 
the patient. After three or four days these symptoms gradually de- 
cline, and the paroxysm of fever yields to a period of remission, during 
which there is almost - complete relief from suffering and fever ; but 
after a few hours, or one or two days, the second period of the disease 
is introduced by the manifestation of jaundice. The temperature rises 
a little, though the pulse continues to fall ; nausea is renewed, and is 
soon followed by the act of vomiting. The matter thus ejected is at 
first watery or bilious, but soon assumes a hemorrhagic character, 
which in fatal cases becomes more intense and frequent until the 
termination of life. The tongue becomes dry and brown, or is 
marked by a red line through its centre. The abdomen becomes dis- 

18 



274 7^^:::: i.v: :vji:::tz iiszasis 

tended and sensitive: black and offensive stools are voided. The 
becomes scanty., high-colored, and albuminous. After two or three 

- - . - .. . . . .- . ■ - : . ._ .. -_.t _ . 

and info the areolar tisane beneath the skin 

. 7 Alter three or four days the severity 
begin to moderate, and convalescence mar quickly follow,, though the 

L:> - : -' :» ~r7 *!:-".; I- - : ' \> < : - T -; . -_ T - ;:-:.- 
greatly prostrated. The poke becomes rapid and feeble, the 





mine is frequently suppressed, a worrying hiccough heralds the ap- 
proaching end ; and the patient; passes into a state of collapse, or 

.i: ' : : .."..:. z. ::' \-'.:.:^ :: :-::" -::;■: 

Paihouogscal A^aj.xt. The *km invariably presents the 
of jaundice, even when it was not apparent before death. AH the 
""'_.". : -_t 'r t::_. :: .::'./.:: :: _-;.-t::-h :h S>:~~ 
times evidences of u^Umamtiem or even of smppmrmtiem mav be 
observed. The ofomZ is darkly fluid and decomposed. The Wmiv 
be nearly normal, or its size is slight! y enlarged ; its color is gray, 
brown, or yellow. The central veins of the lobules and the 
:riz.:ie? :: ~r i-im! - T :. :.:t ^^ t\ ~.:i ':*.:•:.; II f 
cells exhibit evidence of mtry degeneration, being fill« 
drops of oil and granules of pigment. The 

s cedematous and infiltrated with leucocytes. Tin 
enlarged unless previously affected with malarial fever. In 
':: r:":: ■.:. :. :_r~ " : : '_:..-. :l:.:; :,:.. i fxl:':.: r-.lf-i-r :: 
I:. — tt: ::rn; :: :_t -t.-t _tIi :._ _•.. ::.i:> ^:r 
- >: -'.t. 7^-7^7 :l :^7 : ::.; 1 ; :_:.::. : :"_7 :_• t.. l->.l_: :_7 

the chaiacteristic appearances of the large white kidney. Very rarely 

The mils of the eaptiUmwy vemd* also undergo a mtty degeneration, 
identical with what is observed in the capillaries of the attunac h liver, 
and intestinal glands. Similar 

:? fi;-=L ". j ::f Lzl.:lj iT:eir:i:-r ::' :it :_:-:- :: * .m:? ■*!: li^r 
^.7- :j ii-;::::: : :: _ :_t: ->7-:.~7- >_ :..~ 17.7-: :7-::~7~ 

Dia Inedmeases with which yellow fever may be 

Oious innanuuatory fever, and malarial fevers. In oifians 
fever mere is complete iemissiou of all the symptoms 

the third or fourth day" and it is less rapidly and completely 
established than in bilious fever. Albuminuria is rare in the first, but 
is always present in yellow fever. 

Of the mmJbswM fam it is the remittent form that 
degree of resemblance yellow fever. The 
r, begins less abruptly than yellow fever, and is 
ized by an early appearance of jaundice, by repeated 




YELLOW FEVER — FEBRIS FLAVA. 275 

remissions, which contrast with the single invasive paroxysm and 
remission of yellow fever. Malarial fever, complicated with hematuria 
and other forms of hemorrhage, must be distinguished from yellow fever 
by its more continuous or remittent character, and by its occurrence 
during the cool season of the year rather than during the warm. The 
initial chill of malarial fever differs widely from that of yellow fever by 
its greater duration, and by the great prostration that accompanies it. 
while the strength of the yellow-fever patient is more rapidly exhausted 
during the period of relapse. 

From relapsing fever yellow fever must be distinguished by the single 
relapse, and by the greater frequency with which hemorrhage and black 
vomit occur in yellow fever, in contrast with the mildness of the suc- 
cessive relapses that occur in true relapsing fever. 

Acute yelloiv atrophy of the liver can be distinguished from yellow 
fever by the slow and insidious commencement of the disease, and by 
the bilious character of the jaundice that accompanies the invasion of 
the disease. 

Prognosis. The mortality of yellow fever varies considerably in 
different epidemics and in different localities. Negroes and other 
natives of the tropics experience greater immunity from the disease 
than the inhabitants of extra-tropical countries. Northerners who 
experience the disease on removal to inter-tropical localities where it is 
endemic, are exceedingly liable to a fatal result. Consequently the 
mortality of yellow fever is known to vary from ten to eighty per cent, 
of the cases. 

Etiology. Yellow fever is propagated by a contagion of which the 
exact nature has never been determined. It is given off from the 
bodies of patients, and may be transmitted through the air for a short 
distance. It attaches itself to clothing and other movable articles, 
with which it may be conveyed to an indefinite distance. It is thus 
transported in cargoes of merchandise from infected seaports to distant 
countries where it can never become endemic, but where it may origin- 
ate an epidemic prevalence of the disease until its course is terminated 
by the advent of cold weather. For this reason it is believed that the 
active agent of the contagion must be a vegetable parasite that cannot 
survive the freezing temperature. The commencement of an epidemic 
is marked by the appearance of sporadic cases, which multiply and 
become more frequent until an entire population may be infected. In 
like manner, an epidemic gradually subsides, unless suddenly terminated 
by a frost. 

Yellow fever is a disease that prevails among the inhabitants of 
crowded cities upon the sea-coast rather than in sparsely settled regions 
that favor the production of malaria. In these respects it resembles 
the plague and the cholera, with which it forms the triad of migratory 
pestilences. The foul and confined air of ships favors the breeding of 
its contagion, so that the disease may actually become endemic in 
vessels that have been once infected. Only after the most complete and 
radical disinfection can such craft be rendered safe for the transporta- 
tion of human beings. 

The comparative immunity of the negro race has been mentioned. 



276 PAKASITIC AND INFECTIVE DISEASES. 

This immunity depends not upon previous experience of the disease, 
nor upon hereditary causes, for it is said to be possessed by the African 
negroes where yellow fever has never been known, as well as by the 
colored people of tropical America. Mixture with the blood of the 
white races diminishes immunity in proportion to the degree of admix- 
ture. Individual members of other races may acquire immunity, either 
by prolonged residence in the yellow-fever zone, or by actual experi- 
ence of the disease, since, like some other infective diseases, it is pro- 
tective against itself. 

Treatment. There is no specific form of medication for yellow 
fever. Its treatment must be purely symptomatic ; and in general it 
may be said that the less active the treatment the better the result. 
With the commencement of the fever the bowels may be evacuated 
with castor oil ; calomel may be given in doses of a grain every hour 
until fifteen or twenty grains have been administered, or the whole 
quantity may be given in a single dose, which sometimes serves to quiet 
nausea and vomiting. Cold baths must be avoided, but sponging with 
warm water gives favorable results. Infusions of herbs, such as orange- 
leaves, sage, or tea-leaves, are highly recommended. Small doses of 
jaborandi have been used with apparent advantage. During the period 
of relapse treatment must be adapted to the symptoms. Alcoholic 
stimulants, especially in the form of champagne, may be administered 
for the relief of prostration. Anodyne applications may be made to 
the surface for the relief of pain. Astringents and haemostatics are 
generally given in cases of hemorrhage. Suppression of urine requires 
the application of cups to the loins, followed by poultices or other warm 
applications. During convalescence the ordinary tonic and dietetic 
regimen after fever will be required. 



CHAPTER XXVIII. 

CHICKEN-POX— VAEICELLA. 

Varicella is an infective disease of the skin, characterized by an 
eruption of conical or hemispherical vesicles that become rapidly pus- 
tular, followed by desiccation from the fourth to the ninth day. 

Symptoms. Incubation. After exposure to the causes of the dis- 
ease, the period of incubation of varicella is about fourteen days. If 
the disease be communicated by inoculation, the period does not exceed 
eight days. 

Period of invasion. The eruption often appears without previous 
disturbance of the health, but in many cases there is an introductory 
fever that continues about forty-eight hours, and is characterized by 
the ordinary phenomena of fever. The temperature rarely exceeds 
101° or 102° F. Convulsions and other nervous disturbances are 
occasionally observed among young children. 



CHICKEN-POX — VAKICELLA. 277 

Eruption. The eruption is characterized by the appearance of 
minute rounded spots, of a deep-red color, which soon present a papular 
appearance, rising slightly above the level of the skin. After a few 
hours the centre of each papule is occupied by a little hemispherical 
vesicle, which contains a transparent liquid, and is sometimes sur- 
rounded by an erythematous circle. On the second day after their 
appearance these vesicles have reached the size of a small pea, and 
their contents begin to shoAv evidence of purulent infiltration. The 
apex of the pustule becomes thickened and dry. It is the commence- 
ment of the formation of a scab which soon covers the entire pustule, 
and falls off, without leaving any scar, at the expiration of five to nine 
days from the appearance of the papule. The eruption commences 
indiscriminately upon the face, scalp, and body. Vesicles and pustules 
sometimes appear within the cavity of the mouth, upon the conjunc- 
tivas, and on other mucous membranes of the body. The vesicles are 
hardly ever confluent, and are sometimes very few in number. It 
generally happens that the eruption appears in successive crops, so 
that recent vesicles may be discovered in close proximity to pustules 
that are in process of desiccation. In this way the apparent duration 
of the disease may be prolonged for double or treble the time occupied 
by the evolution of a single pustule. 

The fever that characterizes the period of invasion disappears with 
the commencement of the eruption ; but in severe cases that are marked 
by abundant pustulation, a slight fever may be observed during the time 
of suppuration. 

In certain cases the papular stage of the eruption forms its most con- 
spicuous feature. The papules do not become transformed into vesicles, 
and they gradually shrink and disappear after a few days. 

In certain cases, on the contrary, the vesicular process is exaggerated 
to a degree that causes the pustules to assume the formation and char- 
acteristics of bullae, often half an inch in diameter. A distinct zone of 
inflammation forms an areola around the base of each bulla, and ulcera- 
tion takes place with rupture of the bulla and the formation of a dis- 
tinct cicatrix. These exaggerated pustules usually occur as isolated 
incidents in the course of an ordinary eruption, and are the cause of 
the scars occasionally observed upon the face after chicken-pox. 

Diagnosis. The diagnosis of varicella is very easy ; yet by the 
inexperienced it may be mistaken for smallpox, or for certain cuta- 
neous eruptions. From smallpox and from varioloid it may be dis- 
tinguished by the mildness of the fever ; by the rapid evolution of the 
eruption, and by the conical or hemispherical shape of the vesicles, 
which differ from the umbilicated vesicles of smallpox and varioloid. 
Pemphigus, herpes, and certain syphilitic eruptions are said to resemble 
the eruption of varicella ; but the mode of invasion, the peculiarly rapid 
course of the eruption, and its speedy termination are sufficient to dis- 
tinguish chicken-pox from those diseases. 

Pkognosis. Varicella is one of the mildest of diseases, and only 
when complicated by other more dangerous diseases is it ever fatal. 
Gangrene, with fatal results, has been observed among ill-nourished 
children ; and, in rare instances, among patients who appeared to have 



2 7 B PARASITIC AXL INFECTIVE DISEASES. 

been in previous good health. Nephritis sometimes occurs as a com- 
plication of the disease. 

The appearance of the eruption is occasionally preceded by a slight 
erythematous blush, like that which sometimes precedes the eruption 
of smallpox or varioloid. It is a transient phenomenon and soon dis- 
appears. 

Etiology. Varicella is a disease that may be propagated either by 
the diffusion of its contagion through the air : by contact with fomites. 
or by inoculation. The active agent of the contagion is bacterial in its 
character. Staphylococcus pyogenes aureus, staphylococcus viridis 
flavescens. and other micrococci have been found in the pustules of 
varicella. 

Treatment. Uncomplicated varicella requires no treatment, unless 
there be a demand for inunction of the skin to relieve the itching which 
accompanies the eruption. A few doses of antipyrine will suffice to 
moderate the fever and to allay undue nervous excitement. Complica- 
tions, if they exist, require their own appropriate treatment. 



CHAPTER XXIX. 

[SMALLPOX— VARIOLA. 

Variola is an acute, infective disease, characterized by an initial 
fever, that is followed by an eruption of papules which become pustular, 
and are accompanied by a secondary fever. 

The disease is of Asiatic origin, where it has been known among the 
Chinese for thousands of years. It is only since the commencement 
of the Christian era that smallpox has invaded Europe and America. 
Previous to the discovery of its prophylactic treatment, its pestilential 
ravages were frequent and deadly, but in modern times its prevalence 
is the measure of popular ignorance. 

Symptoms akd Course oe the Disease. From the moment of 
exposure to the contagion of smallpox till the conclusion of its course, 
the disease exhibits five successive stages : 1. The period of incubation, 
of which the duration is variable. 2. The period of invasion, charac- 
terized by febrile symptoms which continue for two or three days. 
3. The period of eruption, during which there is an outbreak of papules 
that become vesicular during the course of about four days. 4. The 
period of suppuration, during which the vesicles become pustular, and 
an inflammatory fever is developed. 5. The period of desiccation and 
convalescence, during which the pustules dry up and are covered with 

bs that are shed at the conclusion of the process of cicatrization. 

1. Period of incubation. This stage is usually free from illness, 
though occasional slight disorders of health have been remarked. The 
duration of the period is from ten to twelve 'lays, though cases have 
been reported in which a longer time had elapsed after exposure to the 



SMALLPOX — VARIOLA 



279 



disease. In such instances the entrance of the contagion into the body 
was probably delayed by some unusual circumstance. 

2. Period of invasion. The attack is usually sudden, and is ushered 
in by chills, fever, headache, and intense lumbo-sacral pain. Vomiting 
is not uncommon, the tongue is dry, red at the tip and edges, and is 
covered with a white fur. Young children not unfrequently experience 
convulsions. The temperature rises during the first day to 103° or 
104° F. There is a slight remission the next morning, and during the 
second day a temperature of 106° or 107° F. may be reached. The other 
symptoms of intense fever are present. Occasionally the patient may 
become delirious. Vomiting almost always occurs. The bowels are 
generally constipated, though diarrhoea is sometimes observed. Upon 
the skin an erythematous or a hemorrhagic rash may appear during 
this period. The erythematous rashes resemble the eruptions of scarlet 
fever, measles, urticaria, or erysipelas. The hemorrhagic rashes are 
of a purpuric character, accompanied by petechia and hemorrhages 
from the mucous surfaces of the body. The erythematous rashes are 
chiefly located upon the lower portion of the abdominal surface and in 
the groins, or upon the thighs as far as the knees. They may extend 
along the lateral walls of the thorax, and appear upon the inner sur- 
faces of the arms as far as the elbow. Their duration may be only a 
few hours, or they may persist for a number of days ; sometimes even 
longer than the characteristic eruption of erysipelas itself. 

The period of invasion continues from two to four days ; its length 
is greater in mild cases than in the severer forms. Occasionally the 
patient presents the appearances of a typhoid condition that may be 
prolonged during fifteen or twenty days before the appearance of the 
eruption. 

3. The period of eruption. With the appearance of the character- 
istic eruption of variola there is generally a considerable remission of 

Fig. 87. 




Temperature in modified smallpox or varioloid. (Wunderlicft.) The rapid subsidence 
of the temperature occurs on the third day, with the appearance of the eruption. 
(Fixlayson.) 



the febrile symptoms that mark the stage of invasion. The tempera- 
ture falls, pain ceases, the patient experiences intense relief, and might 
be considered convalescent did not the surface of the body now present 



280 PARASITIC AND INFECTIVE DISEASES. 

a number of minute papules that rapidly enlarge and protrude above 
the level of the skin. These papules appear first upon the forehead, 
about the mouth, then upon the neck and the thorax, extending in 
twenty-four hours over the whole body, though less abundant upon 
those parts of the surface that have been the seat of eruption during 
the period of invasion. Portions of the skin that have been subjected 
to previous irritation of any sort are liable to exhibit an earlier crop 
than appears upon other parts of the body. The papules soon ex- 
hibit upon their summits a minute vesicular point, which rapidly 
enlarges its periphery, becoming translucent and depressed in the 
centre. The umbilication of the vesicle is produced by a remnant 
of connective tissue, bands of which divide the little tumor into sepa- 
rate cavities like the sacs that surround the central pith of an orange. 
This umbilication of the vesicles is less conspicuous upon the face than 
upon the body. 

The evolution of the vesicles occupies three days. Upon the fourth 
dav a red areola appears, surrounding the base of each vesicle. Upon 
the fifth day the contents of the vesicle become purulent, the surround- 
ing skin swells and becomes painful ; the inflammatory process is now 
complete. 

In severe forms of the disease the pustules are placed so near each 
other that their bases are in contact ; upon the face especially the fully 
developed pustules become confluent. In milder forms of the disease 
the full-grown pustules are separated from one another by spaces of 
comparatively healthy skin. In modified forms of the disease the 
pustules may be few in number and far apart. The first variety is 
known as confluent smallpox, the second as discrete smallpox, the 
third form is observed after prophylactic vaccination, and is called 
varioloid. 

The eruption is not limited to the external surface of the body : it 
may appear within the mouth, upon the conjunctiva, upon the mucous 
membranes of the nose, in the pharynx and respiratory passages. In 
these localities the vesicles are soon ruptured, and give origin to little 
patches of ulceration. 

During the period of eruption in discrete smallpox, the fever falls ; 
but during the confluent form of the disease there is only a partial 
remission of fever, and the patient suffers severely with cough, difficulty 
of swallowing, and salivation, caused by the eruption within the nasal 
and respiratory passages. Insomnia and nervous agitation complete 
the misery of the patient. 

4. The period of suppuration. In cases of varioloid the vesicles 
do not suppurate, but in mild forms of smallpox the period of vesicu- 
lation is followed by the transformation of the vesicles into pustules. 
The vesicular liquid becomes turbid through the infiltration of pus 
corpuscles, and the process of inflammation reaches its height upon the 
eighth day after their papular appearance. With the commencement 
of suppuration an inflammatory fever appears, and is characterized by 
many of the phenomena of the fever of invasion. The skin upon 
which the pustules rise begins to swell upon the eighth day. The 
tumefaction increases during the ninth day, but begins to subside upon 



SMALLPOX — VARIOLA. 281 

the tenth day, and disappears during the eleventh. The loose sub- 
cutaneous tissues about the eyes and upon the face become greatly 
swollen : the eyelids cannot be separated, the features are more com- 
pletely obliterated than they are during a course of severe facial 
erysipelas. The hands are considerably swelled, and a similar tume- 
faction is sometimes observed in other parts of the body. Upon the 
soles of the feet and upon the palms of the hands, where the skin has 
been thickened by laborious use, the pustules do not always reach the 
surface, but may be discerned through the thickened layer of epi- 
dermis. 

In the confluent form of smallpox the period of suppuration is char- 
acterized by great swelling of the face and ears, with complete obstruc- 
tion of the nostrils and closure of the eyes, which remain shut for five 
or six days. The patient is nearly suffocated by the salivary secretions 
which decompose in the mouth and throat. There is violent cough, 
the greatest difficulty in swallowing, and the whole body exhales a 
most offensive odor. Delirium is not uncommon, pulmonary compli- 
cations may appear, and death occurs as the result of exhaustion or 
purulent infection. 

5. Period of desiccation. With the commencement of suppuration the 
central portion of each pustule begins to dry, and by the end of the 
eleventh day after the appearance of the original papule the pustule is 
covered by a completely formed scab. These scabs begin to fall off 
about the fifteenth day, and are succeeded by a thin epidermic scale, 
which in its turn falls off, and is replaced by a thinner covering. Three 
or four such desquamative crops may follow each other during the 
course of the following weeks. At the end of from four to six weeks 
nothing remains of the pustule excepting a depressed and purple cica- 
trix, which gradually loses its color, but otherwise remains permanently 
impressed upon the integument of the face. Other parts of the body 
do not exhibit such pitted scars. 

In confluent forms of smallpox the ulcerative process is deeper than 
in the discrete form. The scabs are larger and thicker, and the cica- 
trix exhibits the confluent character of the pustules by which they were 
produced. The fever of suppuration persists for a longer time than in 
discrete smallpox. There is also a greater liability to serious complica- 
tions. Abscesses, diffuse inflammations, and necrosis of the laryngeal 
cartilages may all exist to retard the process of convalescence. 

Varieties. Hemorrhagic smallpox. This form of the disease is 
characterized by a period of incubation of shorter duration than in the 
normal form. The period of invasion is marked by more pain in the 
back, but in other respects the fever presents nothing remarkable. The 
papular eruption is preceded by the various forms of rash that have 
been already described. During the fourth or fifth day of the disease, 
hemorrhagic spots make their appearance over the abdomen and upon 
the limbs. They rapidly extend themselves and form extensive patches 
of ecchymosis, sometimes covering the entire surface of the body. 
Blood escapes from all the mucous surfaces, and is discharged with the 
urine and other excretions. The serous cavities are also the seats of 
hemorrhage. The temperature falls ; the pulse becomes weak and 



282 parasit:; &iri infective diseases 

rapid: there is intense precordial listless, and the patient dies in a 
state of exhaustion, asphyxia, or com Oct tonally c 
served throughout the whole course of the Lisea ae. I son 
occurs before the papular eruption makes its appearance : in others, death 
occur- before the papules have reached the vesicular stage; and in still 
other cases hemorrhage does not occur until the period of suppuration 
ihed. Hemorrhage occurs into the pustules, as well as under the 
forms ahr ribed, and death follows eight or nine days after the 

appearance of the papular eruption. This last variety of smallpox is 
lways fatal; recovery is occasionally witnessed in spite of the 
ity :: the -ymptonis. 

It is worthy of note that the hemorrhagic form of smallpox is very 
commonly served among the victims of alcoholism. It i> also fre- 
quent in epidemics of smallpox that prevail for the first time among 
a population that has had no previ ms experience of the disease. Preg- 
nancy also predis] ises ro its occurrence. 

By this term is —ribed a form of fever 
witnessed during epidemics of smallpox, in which the svmptoms of the 
period of incubation are accompanied or followed by a rash like that of 
ervthema. measles, or of scarlet fever, with:: subsequent papular or 
vesd ilar eruption. Such cases have been considered to be of variolous 
origin. 

In certain cases of smallpox the period of invasion may continue 
from four to six days before the appearance of the eruption I 
other complications intervene, this circumstance does not add to the 
dangers of the di?T 

In certain instances the eruption does not develop beyond the papu- 
stage. These jonstitnte what has been called 

Occasionally the discrete form is accompanied by imperfect 
development of the eruption, and by an intense fever, with great pros- 
tration, and death about the eighth or ninth day. 

Variol This name ie given to an attenuated form of smallpox, 

in which the comparative mildness of the symptoms is due to a pre 
modification of the body by vaccination, or to the occurrence of a prior 
attack of smallpox. It is characterized by moderate intensity of the 
symptoms, and by the rapid evolution of an eruption which does not 
reach the stage : -uppuration. Upon the seventh or eighth day the pus- 
tules begin to and the patient becomes convalescent without the 
occurrence of suppurative fever. The duration of varioloid is from 
eight to fifteen days. ( .m plications may occur, but the progno- - 
generally favorable. The disease protects the patient against smallpox, 
and may communicate true variola to other pers 

Complicat: Variola. These are very numerous, and are 

uent during the period of suppuration. (Ed* 

sometimes occurs, with a fatal result. A , and 

»f the far re sometimes observed. Bronchitis. 

bron>: 

myo> jay involve the respir- 

and circulatory _ ttuiar eru. 'in the i 

and is often a source of great distress. A nay form 



SMALLPOX — VARIOLA. 283 

in the tonsils, diphtheritic or gangrenous processes may involve the 
palate and pharyngeal cavity. Diarrhoea sometimes appears during 
the later stages of the disease. Peritoneal inflammations are rare. 
Parotid inflammation is observed sometimes during the period of 
eruption, in other cases during convalescence. The kidneys may 
become inflamed, with accompanying albuminuria and dropsy. Inflam- 
mations of the ovaries and testes are sometimes observed. Delirium is 
not uncommon during the period of invasion. If it occur during the 
period of eruption, it is an alarming symptom. Among the victims of 
alcoholism it is very common during an attack of smallpox, and gen- 
erally leads to a fatal result. Maniacal symptoms are sometimes 
observed during the period of convalescence. Paralysis is sometimes 
manifested during the course of smallpox, and its gravity is propor- 
tioned to the lateness of its appearance. It is supposed to be dependent 
upon diftuse inflammation of the spinal cord. 

Neuritis and peripheral paralysis are sometimes observed as a con- 
sequence of smallpox, and may be productive of paralyses like those 
produced by acute anterior poliomyelitis. Sometimes the symptoms of 
tabes dorsalis or of disseminated sclerosis are developed, and continue 
for many months before recovery. 

Articular and periosteal inflammations of a simple or of a suppura- 
tive character occasionally occur. 

Intra-muscular hemorrhage is observed sometimes, even in the non- 
hemorrhagic forms of smallpox. During the period of convalescence 
cutaneous abscesses, furuncles, inflammations of the lymphatic glands, 
gangrene of the fingers, toes, tip of the nose, margins of the ears, 
mouth, pharynx, larynx, and genital organs sometimes occur. Ecthyma, 
p>emphigus, acne, and other cutaneous disorders may also harass the 
convalescent patient. 

Blindness, as a result of pustulation of the conjunctiva, ulceration 
of the cornea, iritis, and other forms of intra-ocular inflammation were 
formerly of very frequent occurrence. 

Deafness is sometimes produced by inflammations involving the middle 
or inner ear, or the basilar meninges. Other infective diseases some- 
times follow immediately after the course of smallpox. Previously 
existing diseases are generally aggravated by the intervention of variola, 
though this rule is sometimes reversed, various chronic cutaneous dis- 
eases being dissipated and cured by the intercurrence of smallpox. 

Pathological Anatomy. The papular eruption is the consequence 
of a congestion of the dermal papillae. Each papule marks the seat of 
one of the vascular cones that are connected with the cutaneous arte- 
rioles. As a consequence of the local inflammatory process, the super- 
ficial layers of the epidermis are pushed upward by a liquid exudation, 
and the papule is thus transformed into a vesicle. With the appear- 
ance of leucocytes in the vesicular contents, the vesicle becomes pustu- 
lar, and if the red corpuscles of the blood escape from the capillaries 
the hemorrhagic form of eruption is developed. During recovery the 
epidermal base of the pustule is destroyed, and cicatricial tissue takes 
its place. The papillary structures of the part are not reproduced, and 
the scar remains permanently depressed. The eruption appears upon 



284 PARASITIC AND INFECTIVE DISEASES. 

those surfaces only that communicate with the external atmosphere. 
Occasionally, however, a quasi pustular appearance has been no:^ 
the cesophagus and stomach. The follicular glands of the intestine 
are swelled and intensely congested. The large intestine is occasion- 
ally ulcerated, and pustules have been seen upon the mucous membrane 
of the rectum. An imperfectly developed pustulation and ulceration 
occurs in the respirator si ges. Various pulmonary and intra-tho- 
s on* have already been noted among the complications of small- 
and they may be recognized by their characteristic changes. 

The liver frequently undergoes fatty degeneration. Diffuse hepatitis 
and abscesses of the liver have been observed. The kidneys frequently 
present the appearances of diffuse nephritis. The lymphatic glands 
and the spleen are enlarged. The blood presents the usual appearances 
that have been observed in the course of acute infective diseases. In 
hemorrhagic cases ecchymosis and hemorrhage may be discovered in 
any part of the body. In such cases the capillary vessels : ntain 
numerous bacteria, causing the occurrence of embolism, and possibly 
originating those changes in the vascular walls that determine the occur- 
rence of hemorrhage. 

DIAGNOSIS. During the epidemic prevalence of variola the symp- 
toms of the period of invasion will generally suggest the probability of 
a variolous attack, but in the absence of an epidemic they present 
nothing decisive as a guide for diagnosis. The cutaneous rashes that 

c c c 

appear during this stage may be not unfrequently mistaken for ery- 
sipelas or scarlet fever, measles, urticaria, roseola, erythema, miliaria, 
or even eczema ; but a careful comparison of the symptoms that are 
present with those that should accompany the evolution of such disor- 
ders will soon dissipate doubt. The appearance of the papular erup- 
tion not unfrequently is mistaken for the evolution of other papular 
diseases, such as varicella or the papular form of measles : but the 
variolous eruption may be distinguished, especially upon the face and 
forehead, by a hard, shot-like feeling that is communicated to the finger 
when pressure is made upon the eruptive point. Certain syphilitic 
eruptions closely resemble both the papular and the pustular forms of 
the variolous eruption, but the previous history and the different course 
of the two diseases will soon suffice to distinguish one from the 
other. 

Prognosis. When smallpox attacks for the first time a virgin popu- 
lation, its ravages are frightful. Whole tribes of North American 
Indians were destroyed by this pestilence after its introduction upon 
the American continent. A large part of this excessive mortality is 
due to the prevalence of the hemorrhagic form of the disease : but in 
countries where it is endemic, before the introduction of prophylactic- 
vaccination, a considerable degree of toleration is manifested by a popu- 
lation that has been for ages exposed to the disease. At the com- 
mencement of the present century, before the general introduction of 
vaccination, the mortality from variola among the English people in 
Great Britain and America seldom reached twenty per cent. During 
the epidemic of 1721. in Boston, the mortality was 14.8 per cent. : in 
it was 13.5 per cent.: in 1752 it was 9.7 per cent.: in 1764 it 



SMALLPOX — VARIOLA. 285 

was 18.5 per cent. ; in 1776 it was 9.5 per cent. ; in 1778, during the 
disturbances of the Revolutionary war, it was 34.4 per cent. ; in 1792 
it again fell to 14.2 per cent. Since the introduction of vaccination 
the limitation of smallpox has vastly diminished the aggregate preva- 
lence of the disease in civilized countries ; but the mortality among 
those who do experience smallpox is greatly increased. In the London 
smallpox hospitals, during the present century, from 1836 to 1851, the 
mortality was 37.5 per cent. : from 1852 to 1867, it was 35.7 per cent, 
from 1870 to 1879, it was 44.6 per cent. This increasing ratio of 
mortality is apparently due to a progressive diminution of the heredi- 
tary tolerance derived from ancestral experience of the disease. 

It has always been observed that smallpox is more fatal during epi- 
demic prevalence of the disease than during its sporadic occurrence. 
The mortality also increases with the rise of an epidemic, and dimin- 
ishes w T ith its subsidence. 

The most fatal period in the course of smallpox is the stage of sup- 
puration. The period of invasion ranks next in danger ; then follows 
the period of desiccation. Death occurs least frequently during the 
evolution of the eruption. Hemorrhagic varieties of the disease, and 
severe confluent forms are almost always fatal. The more discrete the 
eruption the less the rate of mortality. Severe nervous symptoms, pul- 
monary complications, and oedema of the glottis, are indications of great 
danger. Alcoholism, pregnancy, previous disease, or exhaustion, add 
greatly to the gravity of the prognosis. 

Etiology. The contagion of smallpox exists in the contents of the 
pustules, and it is near the close of the vesicular period of the eruption 
that its virulence is greatest. Its activity diminishes during the decline 
of the eruption, but it persists in the scab for a long period of time. 
The active agent is probably of bacterial character ; but which spe- 
cies of the several that are found in the liquid contents of the vesicles 
is uncertain. Besides streptococcus pyogenes and staphylococcus pyo- 
genes, which produce suppuration, a number of minute microorganisms 
are known to exist in the virus of smallpox. Similar microbes have 
been discovered in the lymph of vaccine vesicles. These organisms are 
probably absent from the liquids of the body, since they have been 
inoculated into healthy individuals without producing smallpox. The 
virus of variola adheres to clothing and to everything else that is brought 
in contact with the patient. In this way the disease may be transmitted 
from place to place. The dry scabs which are shed from the skin have 
been known to propagate the disease two years after their fall. The 
dust that is formed by pulverization of such scabs, may convey the 
contagion for a limited distance through the atmosphere. The disease 
may thus be contracted by inspiration of an infected atmosphere. The 
victim of the disease thus becomes a centre of contagion from the com- 
mencement of eruption. Certain facts seem to indicate that contagion 
may be derived from individuals during the period of invasion, or even 
of incubation, but it is probable that in all such cases the patient merely 
shares with others the contagion which he has himself received. 

Variola attacks every age, and both sexes ; even before birth the 
infant may become affected by the contagion. In this way may be ex- 



_ : P A R ASITIC _^ X I) I > F E C T I \ z. DISSASKS. 

plained the apparent immunity exhibited by certain individuals who do 
not : ontract the disease after birth. 

Like other pestilential diseases the in:- nsdty : the virus of smallpox 
is increased by overcrowding during epidemics. It is for this reason 
that variola prevails more actively and extensively during winter than 
during the summe: "hen free ventilation can hardly be avoided. 

Warm weather and sufficient ventila: _. fa wever, will not destroy the 
virus. Epidemics of smallpox prevail in mild climates among unpro- 
tected people, with res alts is serious is those that have been observed 
in colder countri-- 

An attack of smallpox usually protects against a return of the disease, 
but there are occasional exceptions to this rule. Lon^ XV : "ranee 
experienced an attack of smallpox when sixteen years of age. From 
this he recovered, but died from a second attack when sixty-four 
years old. 

Trkatm kwt The hygienic management of smallpox is of the 
greatest importance. The patient must be placed in a large and well 
ventilated apartme:.: ; his - Tiling and bedding must be frequently 
changed. The diet must consist of milk, gruel, and broths. The 
bowels mi-: b kept open with gentle laxatives. During the stage of 
invasi on, the fever must be treated upon general principles, by cold 
applications to the head, cool sponge nd the internal administra- 

tion of antipyrine and phenacetine in doses of five to ten grains every 
four hours. With the appearance of the eruption, these remedies 
should be discontinued. Insomnia and severe pain in the back require 
the administration of opiates, but these preparations will be less needful 
if phenacetine has been administered. 

During the period of eruption many remedies have been employed 
for the purpose of aborting the vesicles in order to prevent the fever of 
suppuration, and the subsequent pitting of the face that will otherwise 
disfigure the countenance of the patient. Vaii ;us masks and imper- 
applications to the skin have been employed for this purpose, but 
with little result. Cauterization of the vesicles with nitrate of silver 
has been practised, and a favorable result has been sometimes observed, 
but failure has been probably more common than success: and at 
present the usual practice consists in frequent inunction of olive oil or 
ne. 

Internal medication has also been attempted for the purpose of 
aborting the pastilles. Xylol has recently been recommended for this 
purp: se. It is administered in wine, to the amount of thirty to fifty 
grains a lay; r it may be employed according to the following 
formula : 



R.— XtL;,1 ^ijss. 

\ -- 

MuciL gum. acac. j 
St — Take a teaspoonful every two hoars. 



If 



I i the - me purpose an injection of a two per cent, solution of 
cocaine may be employed r or eight hours, but the depre— g 



SMALLPOX — VARIOLA. 287 

effects of this drug must not be forgotten. A warm bath may be given 
once or twice each day, and the limbs may be wrapped with cloths 
wrung out of warm water during the intervals between the baths. After 
each bath the skin should be powdered with the pulvis salicylicus cum 
talco (salicylic acid 3 parts, starch 10 parts, talc 87 parts). At the 
next bath this should be washed off with soft soap, and again applied 
after removal from the water. The face may be covered with a sali- 
cylic acid paste composed of the following ingredients : 



K . — Acid, salicylic. 
Amyl. pulv. 
Glycerin. . 



lij.-M. 



Resorcin or iodoform combined with vaseline are useful applications. 
Recently it has been proposed to spray the face three or four times a 
day with a solution of corrosive sublimate in alcohol and ether, accord- 
ing to the following formula : 

R . — Hydrarg. corros. chlorid. ") - - 

Acid, citric. 1 aa • * % r ' xv ' 



Alcohol. 



»jss. 



Ether q. s. ad ^ xv. — M. 

During the operation the eyes should be protected by a bandage 
dipped in a solution of boric acid. 

During the period of suppuration salicylate of sodium, in doses of 
fifteen to twenty grains every two hours, will rapidly reduce the tem- 
perature, and diminish the amount of suppuration and subsequent 
pitting. 

Ether and opium have been highly recommended for the prevention 
of suppuration. A syringeful of ether should be injected beneath the 
skin twice a day, and at the same time fifteen or twenty drops of 
deodorized tincture of opium should be administered. The treatment 
should be commenced early in the course of the eruption, otherwise it 
will not produce satisfactory results. The injections should be made 
upon the outside of the leg, between the shoulders, or in the lumbar 
region, in order to avoid the nerve trunks, since they are sometimes 
paralyzed by ethereal injections. Under the influence of this treatment, 
it is claimed that the pustules are aborted, and that the course of the 
disease is considerably shortened. It is, however, useless in hemor- 
rhagic forms of smallpox. 

During the stage of suppuration, the mouth and throat should be 
frequently cleansed with antiseptic gargles, such as a three per cent, 
solution of boric acid ; or chlorate of potassium, one drachm in a pint of 
water ; or salicylic acid, eight grains to the pint. In severe cases com- 
plicated by oedema of the glottis, the surgical measure of scarification, 
or even of tracheotomy, may become necessary. Suppurative fever 
cannot be treated with depressing remedies. Antipyrine and its con- 
geners should be avoided, and the temperature should be reduced by the 
use of cold baths and sponging. The delirium which often occurs in 
cases complicated by alcoholism, may be relieved by rectal injections 
containing thirty or forty grains of chloral hydrate. The strength of 
the patient must be sustained by the frequent administration of egg-nog 



288 PARASITIC AN"D INFECTIVE DISEASES. 

with cardiac stimulants, such as camphor, nux vomica, and capsicum. 
During convalescence the ordinary rules of diet must be observed, along 
with the use of tonics and restoratives. Against the hemorrhagic forms 
of the disease, medicine seems almost wholly powerless. Abscesses, 
secondary eruptions, and other disorders that occur during the period 
of convalescence, must be treated in accordance with general principles. 
Warm baths will always be found useful so long as the skin remains in 
an unhealthy condition. 

Inoculated Smallpox. From time immemorial the practice of inocu- 
lation for smallpox has prevailed in China and in the countries of the 
East, for the purpose of producing a mild form of variola, by which the 
patient is protected against subsequent attacks of the disease. This 
method of treatment was introduced into England in the early part of 
the last century by Lady Mary Wortley Montagu, who had observed its 
utility in Constantinople. Previous to the discovery of vaccination, 
inoculation was extensively practised as a prophylactic against virulent 
smallpox. The mortality of the disease when thus contracted did not 
exceed three in a thousand, among the patients in the London Inocula- 
tion Hospital. Special hospitals were provided for the reception of 
individuals who desired inoculation. They were prepared for the opera- 
tion by regulation of the diet, and by the administration of laxative 
medicines. The virus was taken from selected patients who exhibited 
the discrete form of smallpox, and it was inserted, usually by puncture, 
upon the upper arm. Upon the second day after inoculation, the punc- 
ture became reddened and elevated. Upon the fifth day the papule 
became vesicular ; and upon the seventh day pustulation was complete. 
A red ring then appeared about the circumference of the pustule, and 
enlarged its borders during the eighth, ninth, and tenth days. Upon 
this areola appeared ten or fifteen small satellite pustules. The neigh- 
boring lymphatic glands were enlarged, but their swelling subsided 
about the fourteenth or fifteenth day. The scab that was formed during 
the period of desiccation fell off at the expiration of three or four weeks. 
During the pustular stage, considerable fever was usually observed. In 
mild, cases the satellite pustules failed to appear, and sometimes the 
secondary eruption was manifested without evolution of the pustule at 
the point of inoculation. 

The principal advantage of inoculation consists in the greater im- 
munity against subsequent smallpox that is thus conferred, an immunity 
that is superior to the results of vaccination. The disadvantages of the 
method consist in the occasional development of severe variola after 
inoculation, and in the fatal result that sometimes follows the operation. 
By this method, also, the disease is continually perpetuated in the com- 
munity, and might become epidemic among unprotected individuals. 
Eor these reasons the practice of inoculation has been discontinued in 
all countries where vaccination has been introduced. 

Vaccination consists in the inoculation of variolous virus that has 
been modified and attenuated by propagation through the bovine race. 
It was a matter of common observation, wherever smallpox prevailed, 
that during epidemics of that disease the udders and teats of cows were 
sometimes affected by an eruption that resembled the eruption of variola. 



SMALLPOX — VARIOLA. 289 

It was communicated from animal to animal by the hands of milkers, 
who themselves sometimes contracted the disease. It appeared upon 
the hands wherever an abrasion or other cutaneous wound gave oppor- 
tunity for inoculation. Among the farming population of England, 
William Jenner, then a young surgeon living at Sudbury, discovered a 
prevalence of the belief that milkmaids whose hands had been made 
sore in the way thus described would never contract smallpox. His 
curiosity was aroused, and he made many observations with regard to 
what is called cowpox in cattle. He finally became convinced of the 
prophylactic character of the inoculated cowpox when communicated 
to the human subject ; and in 1796 he vaccinated a patient with lymph 
from the cow. The result proved satisfactory, and after a number of 
experiments in which he vaccinated numerous patients with virus trans- 
mitted from arm to arm, in 1798 he published his discovery to the 
world. After a brief period of contention and experiment, the value 
of the process became fully established, and, from that day to this, vac- 
cination has superseded the old method of inoculation and every other 
prophylactic measure as a preventive of smallpox. 

For a long time it was believed that the vaccine disease originated 
independently of variola, but it has been finally established to the sat- 
isfaction of all but the French school that the two diseases have a 
common origin in the virus of smallpox. Cowpox may be produced, 
though with difficulty, by inoculation of the cow with smallpox virus, 
and the disease thus modified may be transplanted back again to the 
human subject, with the propagation of genuine vaccine disease. It 
has, however, been observed that vaccine lymph thus produced possesses 
a degree of virulence that approaches that of its original source. The 
intensity of the virus may be diminished by successive transmissions 
through the cow, and it is still further attenuated by transmission 
through the human subject. In this way a modified and manageable 
bovine virus may be cultivated that will prove itself efficiently prophy- 
lactic against smallpox without the production of great disturbances, 
such as have been noted when use has been made of fresh cowpox virus 
that is only recently derived from its virulent source in the contagion 
of variola. 

When vaccine virus is inoculated upon the human subject by punc- 
ture, the period of incubation lasts about forty-eight hours. At the end 
of that time a slight papular redness appears at the point of introduc- 
tion. On the third or fourth day the little papule begins to assume a 
vesicular appearance, and rapidly enlarges. The vesicle usually presents 
an umbilicated appearance, and in form the structure is identical with the 
vesicle of smallpox. On the seventh or eighth day the translucent 
contents of the vesicle grow turbid from an infiltration of pus corpus- 
cles. At the same time an inflammatory areola shows itself around the 
pustule and continues to extend itself for two or three days longer. 
Pustulation is now complete. The process of desiccation commences at 
the umbilicated centre of the pustule, which gradually dries into a 
scab beneath which the process of cicatrization takes place. During 
the third week after vaccination the scab becomes dry and hard, and is 
usually shed about the twentieth day. The scar that remains is con- 

19 



PARASITIC AND INFECTIVE DISEASES. 

siderably depressed, and is at first of a purplish color, that gradually 
fades into a dead- white cicatrix marked by numerous minute depres- 
sions or pits. 

The development of the vaccine vesicle is Attended with considerable 
local irritation that is sometimes accompanied by a general febrile move- 
ment during the period of pustulation. The neighboring lymphatic 
glands are often enlarged and somewhat painful. During the period 
of desiccation there is jften intense itching in the neighborhood of the 
pustule, which sometimes leads fcc its rupture by scratching. In this 
the original lesion may become inoculated with pyogenic or ery- 
sipelatous I acteria, which may cause tedious ulceration or diffuse inflam- 
mation. 

The effects of vaccination are usually more intense when performed 
with bovine virus taken directly from the cow. The prophylactic effect 
is also more complete, and is in great measure proportionate with the 
severity of the symptoms that follow inoculation. By long-continued 
employment of humanized vaccine virus, such as has been used in 
England for nearly a century, the effects of vaccination are consider- 
ably mitigated in severity, with a corresponding leterioration of the 
prophylactic result. It has been observed that in countries where such 
attenuated vims is used, the occurrence of smallpox after vaccination 
is a gradually increasing quantity. During the early years of the 
present century vaccination was scarcely evei followed by smallp::; d 
subsequent exposure, but during recent years such an event is not 
uncommon, especially where bovine virus is not employed. So close is 
the relation between the degree of xmstitutionaJ disturbance that is 
produced by vaccination and its prophylactic effect that it is considered 
necessary, at the present time. :: : :::se vaccination by the insertion 
of the virus at not less than four different points upon the arm. 
By this method considerable inflammation and a high grade of consti- 
tutional infection is attained, especially when bovine virus is employed. 
The use of active virus of this character is sometimes followed by the 
appearance of satellite pustules upon the areola, like what are observed 
after inoculation with smallpox vims. It occasionally happens that an 
imperfect attempt at eruption occurs over the surface of the body, but 
this is very rare when ordinary virus is employed. 

Irregular form* :: t are sometimes observed after vaccina- 

The period of incubation may be delayed for a number of days : 
sometimes a considerable papule makes its appearance, but remains as an 
indolent purple tumor, that finally disappears after one or two weeks.- 
Sometimes after such retardation of development an imperfect vesicle 
may occur : in certain cases the vesicle does not present the normal 
umbilicated form, but is cone-shaped or otherwise irregular in its form. 
All such departures from the normal standard should be considered as 
abortive processes that do not confer the necessary n against 

smallpox. 

In the majority ses the pro] hylactic effects of vaccination per- 

sist through life, but in many instances, after a variable period of 
years, the individual again becomes susceptible to the invasion of small- 
pox. For this re necessary. As a precautionary 



HYDROPHOBIA — RABIES. 291 

measure this may be advantageously performed whenever an epidemic 
of smallpox is imminent. It is also advisable to perform re-vaccination 
at, or shortly before, the age of puberty, and after the occurrence of 
any severe illness. 

Mode of vaccination. The operation should be performed during the 
period of infancy. If smallpox be prevalent in the community it 
should be performed immediately after birth, but under other circum- 
stances it may be postponed until the child is three months old. It 
should, however, be performed before the commencement of dentition, 
so as to avoid the period of disturbance that sometimes accompanies 
the eruption of the teeth. It is desirable to choose for the operation a 
time when the health of the patient is undisturbed by other causes, 
though slight ailments or even acute diseases need not contra-indicate 
vaccination in case of exposure of an unprotected person to smallpox. 
The favorite point of vaccination is over the insertion of the deltoid muscle 
on the upper part of the left arm, though other locations are sometimes 
preferred for the better concealment of the resulting scars. The skin 
should be cleansed with soap and water, or with a solution of boric acid, and 
inoculation may be performed either by the introduction of fresh lymph 
obtained by puncturing a vesicle of the seventh day upon the arm of a 
previously vaccinated subject, or with virus prepared by dissolving a 
recent scab in water, or by inserting a fragment of such a scab into a 
little pocket under the skin made by an oblique puncture with the 
point of a lancet. The preferable method, however, consists in the 
employment of bovine virus freshly taken from an inoculated calf, and 
dried upon little ivory points. The skin should be scarified by making 
numerous cross-cuts with the point of the lancet, just deep enough to cause 
the appearance of a slightly sanguinolent lymph. Upon the surface thus 
laid bare the moistened ivory point should be rubbed till the virus which 
it bears has been transferred to the denuded skin of the patient. The 
arm should then be exposed to the air until the lymph has coagulated 
and dried upon the point of inoculation, or the wound may be protected 
by a piece of thin court-plaster. After a day or two, this covering 
may be removed so that the process of vesiculation shall not be dis- 
turbed. The fever and other disturbances that follow uncomplicated vac- 
cination seldom require treatment with anything more than simple 
palliative measures. 



CHAPTEK XXX. 

HYDROPHOBIA— RABIES. 

Hydrophobia is an acutely virulent disease that in man always 
results from inoculation with -the saliva of rabid animals. It prevails 
primarily among wolves, foxes, dogs, cats, and occasionally among 
herbivorous animals. It has never been known to originate spontane- 
ously, but is communicated from one animal to another through wounds 



292 PARASITIC AND INFECTIVE DISEASES. 

inflicted by the teeth. It may thus be communicated to nearly all 
mammiferous animals. 

Etiology. The virus is contained in the saliva of rabid animals. 
When brought into contact with a wound or an excoriated surface, it is 
absorbed, and, after a variable period of incubation, produces the phe- 
nomena of the disease. According to the statistics collected by Pasteur, 
one in six persons who have been bitten by mad dogs experiences hydro- 
phobia. The bite of the mad wolf is much more dangerous, probably 
because of the greater severity of the wounds thus inflicted. Pasteur 
states that in Russia certain death is supposed to follow the bite of a 
rabid wolf. Babes reports forty- two fatal cases among forty-six cases 
of wolf-bites occurring in Roumania. There is no difference between 
the virus derived from the wolf and that of the dog. The only apparent 
cause for greater mortality in one case than in the other appears to exist 
in the greater severity with which the wolf lacerates his victim. 

There is great difference in the fatality that follows wounds inflicted 
upon different parts of the body. A bite upon the head, hands, and 
other uncovered portions of the person, is far more fatal than if the 
teeth of the dog have passed through the clothing of the individual 
before reaching his skin. The virulent saliva is wiped off from the 
teeth as they pass through the clothing, so that very little, if any, 
remains to infect the wound. According to Brouardel, of two hundred 
and seventy persons bitten by mad dogs, one hundred and fifty-two died 
of hydrophobia, and of that number one hundred and twenty had been 
wounded upon the face and the hands. 

Notwithstanding the evidently infective character of hydrophobic 
virus, it has at present been impossible to discover any microorganism 
that can be positively considered as the active agent of contagion. Many 
observers have discovered various species of bacteria in the nervous 
tissues of rabid animals, and cultures of these organisms have occa- 
sionally produced symptoms of rabies in animals after inoculation. 
But nothing decisive has yet been reached in this direction. It is only 
certain that the infective agent exists in the saliva and in the nervous 
tissues of rabid animals. The experiments of Pasteur and of his pupils 
have shown that not only the nervous tissues but also the salivary 
glands, the pancreas, the lachrymal glands, and sometimes also the 
lymphatic glands, contain the virus. When introduced into the circu- 
lation of a healthy animal, either through the lymphatics or through 
the veins, after a period of incubation it produces the symptoms of 
rabies. It is in the brain and in the spinal cord that the contagion is 
chiefly localized. Hence the most certain method of communicating 
the disease from one animal to another consists in inoculation by inject- 
ing under the dura mater a few drops of the liquid prepared by 
triturating with a little water or sterilized broth a fragment of an 
infected brain or spinal cord. 

Symptoms. The period of incubation is of variable duration. The 
shortest period is from one to two weeks, but most frequently it is in 
the course of the second month that the disease is manifested. It is 
rarely postponed beyond the third month after inoculation, though 
cases apparently well authenticated have been published in which the 



HYDROPHOBIA — RABIES. 293 

period of incubation was believed to have lasted for fifteen or eighteen 
months. The period of incubation is usually less when inoculation has 
taken place upon the head and face than when it has occurred upon the 
limbs or other parts at a distance from the brain. The period of inva- 
sion is sometimes preceded by darting pains in the scar of the wound, 
or a sensation of numbness or coldness in the injured part. 

In certain rare cases the development of hydrophobia consists in the 
rapid manifestation of general- spinal paralysis, closely resembling the 
symptoms of acute ascending paralysis. This constitutes the paralytic 
form of the disease ; but in the vast majority of cases the paralytic 
stage is preceded by a period of depression that is followed by muscular 
spasms and general nervous excitement. The period of invasion suc- 
ceeds to the occurrence of cicatricial pains that radiate from the scar of 
the wound. It is characterized by depression of spirits, headache, de- 
bility, a disposition to shun society, and an apprehension of impending 
illness. Sometimes, instead of depression, there is exaltation of the 
organs of sensation, and an intellectual excitement accompanied by a 
disposition to muscular exercise which finds vent in the act of walking. 
The patient walks and wanders aimlessly until quite exhausted. This 
stage of the disease may continue from two to eight days ; it is then 
merged into the stage of nervous exaltation. The first evidence of this 
change is furnished by the muscles of respiration. There is precordial 
distress and a feeling of difficulty in the respiratory movements. Brief 
spasms of the respiratory muscles succeed one another with intervals of 
variable duration. During these attacks the patient catches his breath 
like a person who steps naked into very cold water. The pharyngeal 
and laryngeal muscles soon share in the spasm, and then begin the 
phenomena of hydrophobia. Urged by thirst, the patient desires to 
drink, but the contact of water with the lips and cavity of the mouth 
excites violent spasmodic contractions which involve all the muscles of 
deglutition and of respiration. Even the sight of water, or the sound 
of the liquid as it flows, or the thought of drinking, are sometimes 
sufficient to arouse these spasmodic attacks. It occasionally happens 
that certain liquids other than water can be swallowed, but such cases 
are rare. Usually every effort at deglutition is followed by spasm. 

After a day or two the dry and thirsty mouth becomes moistened by 
an excessive flow of saliva. The patient experiences an irresistible 
impulse to expectorate the frothy liquid, which is sometimes thus in- 
voluntarily ejected upon the attendants. The eyes are reddened, and 
the pupils are considerably dilated. Every sense becomes exalted, 
hallucinations may occur, and the cutaneous hyperesthesia is so intense 
that the slightest current of air is sufficient to arouse a convulsive 
paroxysm. Even the vapor of chloroform, inhaled for the purpose of 
producing anesthesia, may by its odor and by its reduction of tem- 
perature produce intolerable spasms. 

As the disease progresses, general convulsions replace the local 
spasmodic crises ; the voice becomes hoarse, and convulsive cries are 
uttered which have sometimes been fancifully likened to the barking of 
a dog. The patient cannot remain quiet, but must move himself, 
sometimes leaping from the bed, walking, running, or dashing his head 



294 PARASITIC AND INFECTIVE DISEASES. 

against the wall of the apartment in which he is placed. These 
paroxysms become more frequent, and their duration increases, causing 
the patient sometimes to resemble a maniac ; though in the intervals 
between the paroxysms the mind remains clear, and consciousness is 
perfect. These lucid intervals are marked, however, by great depres- 
sion of spirits and a confident anticipation of impending evil. 

As the disease progresses the temperature rises, sometimes reaching 
109° F., the pulse becomes more frequent, the skin is covered with 
perspiration, the urine is scanty and voided sometimes with difficulty, 
the bowels are constipated, venereal excitement may arise, the patient 
sinks into coma followed by death ; or the end may come suddenly 
through paralysis of the heart. The duration of this stage of the 
disease rarely exceeds one or two days. 

In certain cases the period of excitement is followed by complete 
collapse and paralysis that lasts for several hours before the fatal termi- 
nation of the disease. In the majority of cases death occurs upon the 
third or fourth day after the commencement of the disease. Recovery 
is unknown. Reported cases of cure have been probably dependent 
upon an error in diagnosis. 

Diagnosis. The disease may be simulated by an imaginary hydro- 
phobia in nervous persons who have been bitten by dogs that were not 
rabid. In such cases the duration of the disease and the character of 
the symptoms depart widely from the classical features of genuine 
hydrophobia. In certain cases of hysteria the fear of water may 
become a prominent symptom ; but the history of the case, the absence 
of inoculation, the duration of the disease, and the rarity of a fatal 
termination suffice to indicate the real nature of the attack. 

It is probable that the phenomena of tetanus have been frequently 
mistaken for those of hydrophobia. In this way may be explained 
many of the narratives related by the older authors who have described 
a fatal result, preceded by convulsions or spasms, subsequent to a bite 
inflicted by a non-rabid animal, or by a human being who was simply 
under the influence of passionate fury. The two diseases differ in the 
fact that tetanus usually appears within ten days after the wound, 
while hydrophobia in the majority of cases is developed during the 
second or third month after inoculation. Tetanus is ushered in by the 
manifestation of trismus, which is almost always absent in hydrophobia, 
in which disease the spasmodic phenomena are manifested in the muscles 
innervated by the medulla oblongata and the upper portion of the 
spinal cord, while the tetanic spasm is general throughout the muscles 
of the body and limbs. 

Epilepsy has been occasionally mistaken for hydrophobia, but the 
history and course of the disease should obviate the possibility of such 
an error. 

The convulsions of urcemia may be differentiated from those of 
hydrophobia by a fall of temperature that contrasts with its rise in 
hydrophobia. 

Certain cases of delirium tremens may resemble hydrophobia ; but 
the delirium and hallucinations of the alcoholic disease are among the 
earliest symptoms, while in hydrophobia their occurrence is near the 



HYDROPHOBIA — RABIES. 295 

termination of the disease. Difficulty of respiration and pharyngeal 
spasm are among the earliest symptoms in hydrophobia, and are among 
the latest in delirium tremens. There is, however, a sufficient degree 
of resemblance between the worst forms of delirium tremens and 
hydrophobia to embarrass the diagnosis, and to account for many of 
the anomalous cases of alleged hydrophobia. 

Pathological Anatomy. The blood is dark-colored and disorgan- 
ized like that which is found in the bodies of those who have perished 
after the eruptive fevers. The capillary vessels of the brain, spinal 
cord, and nerves are intensely congested. A slight extravasation of 
blood is sometimes observed in the pia mater. The respiratory pass- 
ages are filled with mucus, and the mucous membranes are deeply 
congested. The lungs are also congested, and sometimes contain 
hemorrhagic infarctions. The pulmonary tissue is often emphysema- 
tous. All these phenomena are the result of prolonged respiratory 
spasm. The kidneys exhibit evidences of incipient catarrhal inflam- 
mation. Minute, disseminated foci of acute inflammation have been 
observed in the brain and in the spinal cord ; but nothing character- 
istic or sufficient to account for the symptoms has been discovered by 
the ordinary methods of examination. 

Treatment. The treatment of developed hydrophobia resolves 
itself into a "meditation upon death." Innumerable remedies have 
been essayed for the cure of the disease, but without any positive suc- 
cess. The patient should be placed in a dark room, remote from 
sights and sounds and currents of air, in order to avoid excitement of 
the hypersesthetic nerve tissues. Hypodermic injections of morphine, 
and the injection of solutions of chloral hydrate into the rectum, have 
sometimes given temporary relief, but they in no way modify the course 
of the disease. The only hope of safety for the patient lies in the 
adoption of the prophylactic treatment introduced by Pasteur. As 
speedily as possible after the infliction of a wound by a rabid animal, 
the point of inoculation should be destroyed, by causing it to bleed 
freely, and by the application of the actual cautery, or some other 
equally efficient caustic. The patient should then be subjected to vac- 
cination with the attenuated virus of hydrophobia, according to the 
method described by Pasteur in a communication to the Academy of 
Sciences, October 26, 1885, in which he related his experience with 
the first human subject thus treated. The patient was a boy, nine 
years of age, named Joseph Meister, who had been bitten upon the 
hand and thighs July 4, 1885. The wounds had been cauterized 
with carbolic acid twelve hours after their reception. During ten days 
the patient received thirteen injections of an attenuated virus, and has 
never experienced, during the years that have followed, any symptoms 
of hydrophobia. The publication of this result brought to the labora- 
tory of Pasteur, from all parts of the world, persons who had been 
bitten by rabid animals, so that in 1890 the number treated by Pasteur 
and his assistants had exceeded eight thousand. Of this number a 
large proportion undoubtedly would never have experienced the disease 
had they remained untreated ; but still the results of treatment in 
cases of unquestionable inoculation with rabid virus have demonstrated 



-2?r paba-::: .-.:": ::jz:t:~i diseases. 

the vast superiority of this method over any other that has ever been 
employ ed. In the course of his experimeL E stair had discovered 
that by inoculating a series of animals with virus obtained from the 
spinal cord of the earliest fatal case in each group of the series, it was 
possible to intensify the en^: _ : :be virus with each remove from the 
^ember of the series By this method the periol of incubation in 

: rabbits may be reduced from fifteer 
at which point the intensity of the virus appears to become sta- 
tionary. The process may be reversed, so that by employing virus 
derived from the rabbits that have survived longest after inoculat: 
virus may be produced, after a number of succe- _ tkms, that 

requires the longest eriod of incubation before the development of 
hydrophobic symptoms. Having thus determined the possibil: 
modifying thr fcy of the contagion. Pasteur experimented with 

the view of effecting modification in the intensity of the infective 
gent after its removal from the body of the rabid animal. Having 
ascertained that the brain and spinal cord contain the virulent agent in 
its most concentrated form, he found that by suspending the spinal 
cord of a rabid animal in a sterilised atmosphere, the intensity of its 
virus progressively diminished each day as it dried, until at the end of 
two weeks it became wholly inert. Being provided with such a series 
of drying spinal cords, the animal chosen for experiment is vaccinated 
on the firs: _ by injecting hypodermically an emulsion prepared by 
triturating in water a portion of the spinal cord of the fourteenth da — 
the weakest form of the virus. Upon the second day the animal is 
injected with similar virus from the cord of the thirteenth day ; on the 
third day with virus from the cord of the twelfth day. and so on, each 
day with a stronger virus, until the cord of the second or £: 
reached. Dogs that have been thus treated may then be injected with 
fresh virus from the rabid animal without any unfavorable result. They 
are retraetory to inoeulati 

~ : the vaccination of human subjects, virus prepared by desiccation 
of the cords of rabbits that have died after inoculation is employed. 
The procedure is essentially the same as that already described for the 
protection of dogs. The treatment is continued for ten day- 

the patient receives by hypodermic injection one or two grammes 
of a liquid of which the virulence is increased from day to day. During 
the last day or two. the point of inoculation is surrounded by an 
thematous redness, and there is considerable itching of the adjacent 
integument. The patient is then allowed an interval of one day with- 
out treatment. Upon the twelfth day he is inoculated with virus from 
of the eighth a_ : upon the thirteenth day the 

virus is taken from cords of the seventh and sixth days : upon the four- 
teenth day from the cords of the sixth and fifth days ; upon the fifteenth 
day from cords of the fifth and fourth days ; on the sixteenth day with 
one gramme of virus from cords of the fourth and third days. The 
seventeenth day passes without treatment. From the eighteenth to the 
twenty-sixth days the patient is inoculated each day with two grammes 
taken successively fro:: _ sixth, fifth, fourth, 

and thirl :er which treatment is suspended. This method has 



MANAGEMENT OF INFECTIVE DISEASES. 297 

been varied by different experimenters who have practised intensive in- 
oculation by reducing the interval between the successive injections from 
one day to twelve hours, or even less. Great success has attended the 
intensive method of inoculation as practised in the Pasteur Institute at 
Chicago, where the aggregate mortality thus far has been less than 
one per cent. 

The mortality among patients subjected to this method of treatment 
at the Pasteur Institute in Paris was one and thirty -four one-hundredths 
per cent, in 1886 ; one and twelve one-hundredths per cent, in 1887 ; 
seventy-seven one-hundredths of one per cent, in 1888 ; fifty-four one- 
hundredths of one per cent, in 1889 ; thirty-two one-hundredths of one 
per cent, in 1890. Similar results have been obtained elsewhere ; so 
that, although the method of treatment by vaccination does not afford 
an infallible means of prophylaxis, it ranks among the greatest thera- 
peutical discoveries ever given to the world. 






CHAPTEE XXXI. 

ON THE MANAGEMENT OF INFECTIVE DISEASES. 

The attempt to control the prevalence of infective diseases resolves 
itself into two distinct, yet nearly related lines of action. The personal 
care of each individual patient falls within the province of the attend- 
ing physician, and he alone is responsible for the necessary medical 
treatment. But the care of the public health is in every well-regulated 
community specially delegated to the regular staff of the health office. 
The duties of this office are divided between the prevention of imported 
diseases and the supervision of domestic pestilences. 

The discovery, a few years ago, that the majority of infective dis- 
eases are due to the invasion of parasitic microorganisms, was accom- 
panied by the belief that such diseases inevitably follow exposure to 
their contagia, and that if such contagia could be avoided or destroyed 
the infective disease might be completely and forever arrested. The 
majority of the methods for the prevention of spreading diseases that 
are now in use were based upon this belief, but with the progress of 
investigation it appears that the parasitic contagia of many diseases 
are so widely and so abundantly disseminated that by no precau- 
tion can they be avoided. The existence and production of immunity 
against disease was not then understood as it is at present, though here 
and there thoughtful observers did not fail to recognize the fact of such 
immunity. It consequently has become necessary in some respects to 
recast many of the rules and sanitary regulations that were formulated 
a o-eneration ago. 

It will be found nearly always impossible in dealing with the major- 
ity of mankind to secure those ideal conditions which are most favor- 
able to the recovery from sickness and the safety of the community. 



PARASITIC AND INFECTIVE DISEASE-. 

It is. however, well to keep in mind an ide a*d which the 

efforts of the physician should be directed, even though it be imposs 

.lize anything more than a partial approach toward that perfection 
which only wealth and : : ran lless resources can afford. 

So far as possible the sick should be separated from the well. When 
this can be effected in the home of the patient he should be placed in a 
separate apartment remote from the rest of the family, and should be 
visited only by the physician and by the necessary attendants. The 
sick room should be large and airy, with an open fireplace, in which a 
sufficient fire should be kept during the winter, in order to insure suffi- 
: ient ventilation and warmth. The floor should be uncarpeted : the 
walls either painted or whitewashed ; the windows provided with simple 
screens, without hangings or heavy curtains. The utmost cleanliness 
should be maintained in all the surroundings of the patient, and all the 
excreta should be removed as soon as voided, and thoroughly disinfecte 
with milk of lime, in typhoid fever, or with carbolic acid, permanganate 
of potassium, n rther disinfectants, as the particular may 

require. In order to prevent the escape of the effluvia into other parts 
of the dwelling, the door of the apartment should be guarded by a 
sheet hanging upon the outer side of the door-frame. It has 
advised by some authors to keep such a curtain saturated with a dis- 
infecting fluid, but such an expedient will be rendered unnecessary by 
the use of a Canton-flannel curtain, or by the employment of a com- 
forter wadded with cotton, which forms a filter much more effectual to 
arrest microphytic organisms than a simple piece of sheeting that is 
only occasionally moistened with a disinfecting fluid. In dealing with 
infective discharges, like those from the mouth and throat in cases :: 
diphtheria, it is advisable to receive them up>on soft rags that can be 
immediately burned without removal from the sick room. Clothing. 
articles : riling, and other objects that have been in contact with 
the patient, should be placed in a disinfectant solution before removal 
from the apartment, that they may not convey contagion : those who 

re them to be washed. In all things the utmost cleanliness 
should be practised, and by the aid of abundant soap and hot water. 
and the ordinary solutions of carbolic acid or permanganate of r 
sium. corrosive sublimate, boric acid. etc.. such cle ffi may be 

secured without difficulty, especially when supplemented by the frequent 
baths that are demanded as a part of modern medical treatment. 

Diseases that are followed by desquamation, like scarlet fever and 
measles, require the use of vaseline or other unguents during the period 
of convalescence, in order to prevent the diffusion of epidermal scales 
through the air. Such applications should be rendered disinfectant by 
the addition of resorcin. salicylic ac: I \. eucalyptol, and 

other similar substances. By their use and by the employment of daily 
baths and disinfectant soaps, the period of desquamation and of infec- 
tion may be sh weeks after scarlet fever. In every 

the physician should seek by the use fa fc and efficient disinfect- 
ants : y the inf. : -reta and effluvia by which the dif 
_ I 

:• time of isolation must vary according t the liseasc and 



MANAGEMENT OF INFECTIVE DISEASES. 299 

according to the individual peculiarity of the patient, consequently it is 
impossible to lay down any fixed rule that will be effectual to prevent 
by quarantine the communication of disease. Some cases of scarlet 
fever cease to be infective within a few days after the disappearance of 
acute symptoms, while others may communicate the disease for six 
weeks or two months. A diphtheritic patient may sometimes continue 
infective for many months after the appearance of the first symptoms of 
his disease. The principal reliance, therefore, should be placed upon 
disinfection on the part of the patient, and upon the production of im- 
munity on the part of the well. 

After the occurrence of infective disease in a house or apartment a 
thorough cleansing of the premises should be effected. It has been 
advised to burn sulphur in the infected apartment for the purpose of 
destroying the microorganisms of disease ; but this measure is not any 
more efficient than a thorough scrubbing of the w T ood-work with hot 
water and soap, followed by the application of paint or whitewash to 
the walls and ceilings. Mattresses, pillows, and articles that cannot be 
thoroughly washed should be exposed for several hours to the action of 
heated air in a disinfecting stove, in which the temperature of 250° F., 
or more, can be steadily maintained. 

For disinfecting and deodorizing purposes the sulphate of iron, one 
pound in a gallon of water, for use where it will not come in contact 
with' clothing ; chlorinated lime, six ounces to a gallon of water ; milk 
of lime, prepared by adding one part of the hydrate of lime to eight 
parts of water ; and carbolic acid in a five per cent, solution of the 
pure acid, are the safest articles for use among the common people. 
Corrosive sublimate and other disinfectants and antiseptics are only to 
be used under the direct supervision of the attending physician. 

In dealing with infective diseases like cholera, yellow fever, small- 
pox, etc., which are not endemic, but are liable to importation from 
foreign countries, an efficient quarantine service is necessary at every 
port of entry. Here, again, the exigencies of commerce have brought 
to light the efficacy of thorough disinfection in dealing with yellow 
fever and cholera. In countries where the old-fashioned faith in quar- 
antine, sanitary cordons, and isolation still prevail, but little success is 
obtained in the attempt to exclude these foreign pestilences, while the 
principal commercial nations of the world, Great Britain, Holland, 
and America, have reached the most gratifying results by reliance upon 
disinfection. By efficient inspection of passengers and cargoes, the 
existence of contagion may be ascertained, and the necessary measures 
for disinfection can be completed within the space of a few hours, where 
days and weeks were formerly required, too often without satisfactory 
results. Detaining only the sick for treatment in quarantine hospitals, 
travellers without disease may be safely permitted to pursue their course 
if only their clothing and other effects are subjected to disinfection by 
heated air, or by washing with boiling water and disinfectant solutions. 

The sanitary control of endemic infective diseases requires the most 
skilful and delicate management on the part of officials intrusted with 
the care of the public health. In every considerable community, a 
health officer is a public necessity, but it should be never forgotten that 



300 PARASITIC AND INFECTIVE DISEASES. 

if insufficiently equipped with material and intellectual resources, the 
health office can easily become a nuisance instead of a benefit to the 
community. In no position is there greater need of knowledge, skill, 
and tact than at the head of a municipal department of health, for it is 
necessary to deal with all classes of people, under the most trying situ- 
ations in life. Whenever possible, the office should be filled by an 
experienced physician, who. however, is not engaged in the practice of 
medicine. The exactions of an enormous foreign commerce have 
stimulated the leading nations of the world to the adoption of the 
latest and best fruits of scientific investigation in the matter of quaran- 
tine : but unfortunately no such pressure is brought to bear upon 
domestic sanitarians. Consequently, in the matter of dealing with 
endemic diseases, very little progress has been made since the time 
when attempts were made to arrest the progress of the plague by nailing 
placards upon the doors of infected houses, and locking up their inmates 
to die without assistance. 

In the endeavor to arrest the spread of infective disease the first 
thing that is needful is to secure early information regarding the loca- 
tion and character of such diseases as are placed under the supervision 
of the municipal officials. For this purpose it is desirable to enlist the 
aid of every physician : but, since it is obviously improper for a physi- 
cian to furnish information regarding a patient which that patient and 
his friends are not required to furnish, the regulations of the health 
department should require notification in case of infective disease, by 
the nearest friend or relative of the patient. For such notification no 
compensation need be rendered, since such notification is a duty incum- 
bent alike upon all under similar circumstances : it is a service rendered 
by the patient himself for himself. Since, however, such reports from 
unprofessional people can be obtained only with difficulty, if at all. the 
principal reliance should be placed upon notification by the attending 
physician, who should in every instance be paid by the municipal 
authorities a stipulated sum for each notification, just as he should be 
paid for every professional service rendered either to the public or 
to his private clients. 

Having obtained information regarding the existence of infective 
disease, the health officer should proceed to verify the fact by a con- 
ference, either in person or by deputy, with the attending physician. 
The same professional rules that govern ordinary consultations should 
be observed in this matter, otherwise friction will inevitably arise 
between the attending physician and the health officials. All commu- 
nications from physicians to the health officer regarding disease should 
be of a confidential character, and should never be open to inspection 
by the public. If this rule be not observed, that freedom of commu- 
nication between the central authority and medical practitioners which 
is so desirable will cease to exist, for the mass of physicians will not 
tolerate the publication of details regarding their practice which must 
come under the eye of a sanitary inspector. 

In dealing with the different infective diseases that are endemic, or 
that may become epidemic, different methods are necessary. Smallpox 
can be readily eradicated by universal vaccination, consequently the 



MANAGEMENT OF INFECTIVE DISEASES. 301 

principal effort of the sanitary authorities should be directed to the 
accomplishment of this end. In communities where public schools are 
maintained, it is sufficient to require a certificate of vaccination from 
every child on admission to school. In this way the same result is 
indirectly reached, without objection on the part of the public, which 
otherwise can be only obtained with great difficulty and much dissatis- 
faction when compulsory infant vaccination is demanded by law. It is 
impossible in any considerable population to deal properly with small- 
pox unless sufficient hospital accommodation for variolous patients can 
be provided. The smallpox hospital should be as far from other habi- 
tations as possible without rendering a journey thither dangerous to the 
sick during severe winter weather, for patients should not be trans- 
ported far from their homes during the inclement season of the year. 
Only during the interval between the invasive fever and the commence- 
ment of suppuration can such exposure be safely tolerated in severe 
forms of the disease. When removal is impracticable, it is sufficient to 
isolate the sufferer in his own home, affording protection to others by 
vaccination and re-vaccination of everyone in the neighborhood of the 
infected house. 

Cholera patients can be safely treated in their own homes, provided 
sufficient provision can be made for their care. The principal effort of 
the sanitary official should be directed to the disinfection of the premises, 
clothing, bedding, etc., that have been soiled. The most efficient method 
of dealing with an epidemic of cholera consists in visitation from house 
to house by a properly appointed corps of visitors, whose duty it is to 
distribute circulars containing information regarding the disease, and to 
administer the approved remedies to all persons whom they may find 
suffering with diarrhoea. In many cases certain religious orders have 
furnished most valuable aid in such house to house visitation ; and in 
severe epidemics of the disease such assistance is indispensable. 

An epidemic of yellow fever requires similar management, but it is 
desirable to disperse the population upon whom the disease is incident. 
The population of a plague-stricken community should be encouraged 
to leave their homes, and to seek a non-infected locality, even if it be 
only a short distance outside of the town or city in which the epidemic 
prevails. Thorough disinfection will accomplish all that can be effected 
until the return of cold weather destroys contagion. 

Typhus fever and relapsing fever are diseases that require for their 
extermination little besides good feeding, thorough ventilation, and 
efficient disinfection. The sick should be taken out of their filthy dens, 
and be placed under canvas, or in airy wooden pavilions during the 
inclement season of the year. Only when left to herd together in filth 
and poverty, or when overcrowded in almshouses, barracks, and unven- 
tilated hospitals, does the disease become dangerous to a well-fed 
American community. 

In the attempt to deal with infective diseases no inflexible rules or 
municipal statutes should be laid down for the guidance of the health 
office, excepting those general provisions that are needful to place ex- 
ecutive authority in the hands of the health officer. The fact should 
be recognized that our methods of dealing with epidemic disease are 



302 PARASITIC AND INFECTIVE DISEASES. 

still in the experimental stage, and there should be opportunity for 
continual experiment and innovation in the attempt to control such 
diseases. Nothing can be more unfortunate than a routine method on 
the part of sanitary officials. The tendency in this direction is at the 
best too strong in all municipal corporations, and it should be resisted 
to the utmost. This tendency to fall into a rut is especially liable to 
occur in connection with the endemic diseases of a community, since 
in a large city the ordinary occurrence of such disorders is not very 
conspicuous, and at the same time they are too commonplace to arouse 
anything more than a languid interest in the minds of the public and 
of the medical profession. The sufferers themselves who are benefited 
or damaged, as the case may be, by the treatment that they receive at 
the hands of the officials, are usually voiceless, and their praise or 
their protests pass unheeded. It is for this reason that, except in a 
few favored localities, the efforts that are made for the improvement of 
the public health are often most unwisely conceived and inefficiently 
executed. Habitual abuses remain for years unchecked, without the 
slightest attempt for their removal, until they become crystallized and 
sanctioned by antiquity. 

It is impossible for any health officer, however skilled or well-dis- 
posed, to cope with endemic disease in a large city unless he has at his 
command the resources of a well-equipped hospital provided for the 
special reception of such diseases. Without such a hospital he is one 
of the most helpless and useless persons in the community. In every 
large city more than one such hospital is needed, so that the buildings 
may be easily accessible from all parts of the town. In small cities 
and in country districts, something after the plan of the English Cot- 
tage Hospitals will be sufficient. These hospitals, however, should not 
be used for any but the needy members of the population, who cannot 
procure attendance and sufficient isolation in their own homes. Having 
received notification of the existence of infective disease in a particular 
house, the health officer should ascertain whether such attendance 
and isolation can be secured by the patient ; if that be the case, further 
interference on his part is unnecessary, unless it be for the purpose of 
distributing information to the inhabitants of the infected house, and 
securing sufficient disinfection of the premises after the conclusion of 
illness. But if the poverty of the patient render it impossible to secure 
necessary attendance, isolation, and disinfection, as when, for example, 
he is a poor laborer living in a cheap boarding-house, or when the 
family of the sufferer occupy quarters in connection with their place 
of business, so that they cannot continue their daily avocations without 
exposing customers and strangers to infection, the patient should be 
removed to the hospital. If it be needful for the safety of the public 
thus to remove little children, the mother or other near relative should 
be permitted to accompany the child, and to remain with it during its 
treatment in the hospital. In this way many prejudices can be easily 
overcome. 

In belated communities that are still under the influence of mediaeval 
notions, great efficacy is ascribed to the practice of placing placards 
upon infected houses. It is true that by this method the largest pos- 



MANAGEMENT OF INFECTIVE DISEASES. 303 

sible display of official authority is secured with the smallest expendi- 
ture of useful energy ; but the practice is objectionable for several 
reasons. It is thoroughly repugnant to the feelings and prejudices of 
the majority of people ; it is an occasion of great alarm and anxiety 
on the part of unintelligent neighbors ; and is usually a signal for de- 
sertion of the afflicted family by the servants whom they may have 
employed in the house. AVorst of all, it prevents many persons from 
acknowledging the existence of infective disease in their houses, and 
the health official thus remains frequently ignorant of the extent to 
which certain diseases are prevalent ; for, however much the fact may 
be denied, it still remains true that the concealment of infective dis- 
ease is a very common incident in large cities where placards are used. 
In this respect human nature remains unchanged since the days of the 
great plague in London, when people tore down the placards that were 
fixed upon their houses, and could be only restrained by an army of 
special police. Similar scenes were enacted in Philadelphia when an 
attempt was made to placard houses during the great epidemic of yellow 
fever in the days of the famous Dr. Rush. The terrified population 
resisted the attempt, would have nothing to do with physicians or 
health officers, who were consequently obliged to stand paralyzed until 
the offensive enactment was withdrawn. In small rural communities, 
where the majority of families are independently comfortable and 
sufficient unto themselves, a placard works little inconvenience, and 
may be tolerated ; but in a crowded city population, where such notices 
often mean the destruction of a poor man's business and starvation for 
the inmates of a quarantined residence, continual evasion of the law 
will occur. The use of placards, therefore, should be discretionary 
instead of compulsory, and they should be displayed only when in- 
sufficient isolation of a patient cannot be secured in his home. It is 
for this reason that in every municipality special hospitals are so 
necessary, in order to make provision for patients who cannot be with 
safety to the population left in their own homes. It should be never 
forgotten that the public has no right to destroy the business of any- 
one without full compensation for the time and property that have 
been rendered useless in the effort to protect the public health. Such 
reckless interference with the rights of poor people frequently occurs 
through the indiscriminate use of placards; all of which might be 
avoided by removing the infective patient to the proper hospital. 

Another weighty objection to the indiscriminate use of placards con- 
sists in the fact that where they are employed, they become the principal 
reliance of the sanitary officials, who, having nailed a warning card 
upon an infected house, subside into a state of utter indifference regard- 
ing any other duties than the preservation of their sign-manual for a 
given number of days. Medical attendants, infected families, and all 
parties concerned, insensibly fall into the habit of reliance upon this 
species of quarantine, and the proper measures for disinfection are 
neglected. A certain feeling of resentment also grows up in the hearts 
of the sufferers, and they become indifferent to the communication of 
contagion among their neighbors. Little by little this feeling of neg- 
ligence involves the uninstructed masses ; from the extreme of panic 



?a?.as:::: av: :yjz;::Ti ::-zaszs, 

they pass to the extreme of ning placards are 

finally regarded with the same indifference with which ordinary p 
are read. 

Public funerals after death from the virulent infective diseases 
should not be allowed. 

In many localities it is customary to exclude from the public schools 
children who belong to infected families, even though they be thena- 
rs free from disease. This regulation, how T is useless, since 
those children, if not in school, will be generally found upon the streets 
mingling freely with their playmate. T attempt their confinement 
within their infected homes would only subject them to greater dan; 
infection, and would also intensify the virulence of the disease when 
experienced. Children who are ill should be. of course, excluded from 
the schools until they can produce a medical certificate of complete 

: t_ - : but while the great object of isolation should be the separa- 
tion of the sick from the well, it should not be carried so far as to 
include the well within the limits of quarantine. Every attempt to 
enforce rigid quarantine among the masses of a large city in the case 
of ordinary endemic diseases, produces hardships and evils that are 
worse than those which are caused by disease itself. 

The attempt to suppress the extension of gyphili* has been often 
undertaken by sanitary officials in many of the large cities of the world, 
but it has always resulted in signal failure. It is true that in semi- 
barbarous and partly isolated communities, where men and women are 
treated like animals, and can be subjected to military discipline and 
despotic rule, a certain degree of success —cured by frequent 

inspection and treatment of prostitutes : but this result is obtained at 
the cost of much that is invaluable in a free, enlightened, and moral 
community. For these reasons it is now acknowledged by the leaders 
: social science that syphilis can be most effectually controlled by 
those indirect methods that elevate the character and welfare of the 
population. Prosperity, education, and moral progress are more efficient 
barriers to the spread of syphilis than any that can be provided by the 
ordinary guardians of municipal health. 

The recent demonstration of the infective character of tuberculosis 
has in certain quarters been followed by the agitation of propositions 
for the compulsory suppression of tubercular disease. In this case, 
however, as in many others, a knowledge of the history of tuberculosis 
during pu- . would preserve many well-meaning sanitarians from 
rig endeavors accomplish that which can be only 
effected indirectly through the gradual progress of the population in 
wealth, civilization, and comfort. For many years pulmonary consump- 
tion - ^.uthern Europe considered a highly infective disr—. li- 
the city of Naples physicians juiied to report to the health 
officer every case that came under their observation, under penalty of 
an enormous fine and banishment for ten years. The patien: 

sti ized like a It *uded from employment, and his family 

were reduced to beggary. After death the rooms that he had inhabited 

completely eviscerated and thoroughly rebuilt ; yet despite all 

nsumption continued its ravages, and the 



MANAGEMENT OF INFECTIVE DISEASES. 305 

death rate from that cause was higher than in other cities, thus fur- 
nishing an excellent illustration of the utter futility of every attempt to 
suppress endemic disease by methods that do not substantially improve 
the habits and welfare of the population. In this connection it should 
be always remembered that, unless some radical improvement be 
effected in the habitations, provisions, occupations, and character of 
the population, no great change in the general mortality can be pro- 
duced by mere sanitary rales and regulations. The suppression of 
smallpox has been followed by an increased mortality from scarlatina ; 
the suppression of scarlatina and measles has been followed by an in- 
creased mortality from diphtheria, typhoid fever, and diarrhoea. The 
preservation of infant lives has for its principal result an increased 
mortality in early and middle adult life, at the time when existence is 
sweetest and most valuable. Consequently it is not worth while to 
attempt the improvement of public health by methods that are arbitrary, 
violent, and repugnant to the feelings and prejudices of the commu- 
nity. Indirect methods that improve the hygienic environment, pros- 
perity, and comfort of mankind alone give an abiding and satisfactory 
result. 



20 



PART III. 

DISEASES OF THE ALIMENTARY CANAL. 



CHAPTEE I. 

DISEASES OF THE MOUTH. 

Catarrhal Inflammation of the Mouth — Stomatitis Catarrhalis. 

Etiology. Stomatitis is generally caused by irritants of a thermal, 
mechanical, or chemical character. Extremely hot or cold articles of 
food or drink, or excessively heated air, may excite inflammation of the 
mouth. Among mechanical irritants may be enumerated the forcible 
intrusion of sharp and angular, or ragged bodies. In like manner, 
broken teeth, and projecting particles of tartar may excite inflamma- 
tion. It occurs, sometimes, among very young infants as a consequence 
of excessive efforts in the act of nursing, or as a consequence of improper 
food. Violent screaming and shouting may cause inflammation by 
extension from the larynx to the pharynx. 

Among chemical causes may be mentioned the excessive or improper 
use of certain drugs — e.g., iodine, bromine, arsenic, lead, mercury, 
nitrate of silver, mineral acids, caustics, irritating gases, alcohol, and 
tobacco. The regurgitation or vomiting of acid liquids from the stom- 
ach, and the decomposition of particles of food which have lingered in 
the mouth, may also occasion inflammation. It frequently accompanies 
general ill-health, such as may be produced by chlorosis, anaemia, and 
scurvy, or by chronic diseases of the heart and lungs, which interfere 
with the circulation of the blood, and by infective diseases. It often 
accompanies the processes of dentition. 

Pathological Anatomy and Symptoms. Acute catarrhal inflam- 
mation of the month commences with sensations of heat and dryness in 
the oral cavity. The mucous membrane is painful on pressure. Its 
secretions are diminished; though, at a later period, they may be so 
exaggerated that the saliva flows over the lower lip and produces ery- 
thema upon the chin. The reaction of the saliva is usually acid. The 
senses of taste and smell become perverted ; there is complaint of a 
bad taste in the mouth ; and the breath exhales a disagreeable odor, 
in consequence of decomposition of the products of exudation. The 
inflamed mucous membrane appears excessively reddened and swelled. 
The tongue appears broader than is natural, and its borders are 



308 DISEASES OF THE ALIMENTARY CANAL. 

indented by the teeth. The inner surfaces of the cheeks are similarly 
indented. Sometimes the follicular glands of the mouth are inflamed, 
and project in the form of little warty prominences which, on pressure, 
yield a small quantity of puriform liquid. Their rupture is not unfre- 
quently followed by the formation of small ulcers. The epithelial cells 
of the mucous membrane are exfoliated in considerable quantity, pro- 
ducing a more or less thick coating upon the tongue and other mucous 
surfaces. Sometimes the fungiform papillae of the tongue appear above 
the epithelial layer in the form of red and tumefied prominences about 
the size of a small pinhead. 

The general symptoms are usually moderate, except in very young 
children, who sometimes exhibit the phenomena of high fever or convul- 
sions. The duration of the disease rarely exceeds one week, though 
chronic catarrh may linger with a moderate degree of intensity for a long 
period* of time. 

Diagnosis and Prognosis. The diagnosis of catarrhal inflamma- 
tion of the mouth is not attended with any difficulty if one keeps in 
mind the fact that something more than mere coating of the tongue is 
necessary to constitute the inflammatory process. Newly born children 
always manifest during the first days of life an increased redness of 
the oral cavity, which is occasioned by purely physiological processes 
dependent upon the first use of the mouth. 

The prognosis in acute cases is always favorable. Chronic cases 
which are dependent upon errors of diet, smoking, drinking, etc., usually 
linger so long as their causes are operative. 

Treatment. In addition to the discovery and removal of the ex- 
citing cause of catarrhal inflammation, it is only necessary to employ 
frequent gargling of the mouth with cold water and with a 2.5 per cent, 
solution of chlorate of potassium every two hours. Young children who 
cannot gargle may have their mouths syringed with the solution. Other 
excellent gargles are salicylate of sodium (2 per cent.), carbolic acid (2 
per cent), permanganate of potassium (a teaspoonful of a 1 per cent, 
solution in a glassful of water), liquor aluminii acetici (a teaspoonful of 
a 5 per cent, solution in a glass of water). Chronic inflammation may 
be successfully treated by daily applications of a solution of corrosive 
sublimate (0.001 per cent.), or of nitrate of silver (1 per cent.). 

Ulceration of the Mouth — Stomatitis Ulcerosa. 

Etiology. The principal indications of this disorder arc severe 
ulceration of the gums attended by an extremely offensive breath. The 
disease sometimes occurs epidemically among the poor, and in ill-man- 
aged institutions where large numbers of feeble children are crowded 
together without proper eare. Among adults it is most frequently 
encountered among weakly individuals who are the victims of cachexia. 
It usually occurs during the period of dentition. 

A special form of ulceration of the mouth sometimes follows the 
excessive use of mercury. Lead, phosphorus, and copper, occasionally 
produce a similar form of the disease. 



DISEASES OF THE MOUTH. 309 

Pathological Anatomy and Symptoms. The disease commences 
with a sensation of heat and soreness in the mouth, which is increased 
on taking food. The inflammatory process arises usually between two 
adjacent teeth, along the free border of the gum on the lower jaw. 
The mucous membrane swells, and bleeds freely upon the slightest 
touch. In the course of one or two days the process of ulceration is 
complete, and upon the gum appears an ulcer with a dirty-gray surface, 
which is made up of detached epithelial cells, pus corpuscles, blood, 
bacteria, and detritus. The ulcerative process gradually extends to 
the inner margin of the gums, and may involve the opposite surface of 
the tongue or of the lips and cheeks. The sockets of the teeth are 
also invaded, so that the teeth become loosened and fall out, or may be 
removed without pain. The jawbone itself may become inflamed and 
necrosed. The odor of the breath is horribly offensive. The adjacent 
lymph glands become enlarged and tender. The salivary glands yield 
a copious, acid, sometimes bloody and offensive, saliva. There is often 
considerable fever accompanied by symptoms of general infection, but 
the local processes are restricted to the mouth and its dependencies. 
There is often great exhaustion as a consequence of the difficulties 
which attend deglutition, together with loss of appetite and power of 
digestion. In acute cases the disease runs its course in about two 
weeks, but the chronic form continues for several months. 

Mercurial stomatitis does not essentially differ from the ordinary 
form of the disease. It is often ushered in by a metallic taste in the 
mouth, and a feeling as if the teeth were loosened in their sockets. 

Diagnosis and Pkognosis. The prognosis is almost always favor- 
able, and the diagnosis is equally easy. 

Treatment. The mouth should be thoroughly gargled, every two 
hours, with a 2 5 per cent, solution of chlorate of potassium. Liquid 
food, stimulants, and tonics (Elixir calisayae, half an ounce, three times 
a day) should be given until the health is restored. 

Stomatitis Aphthosa. 

Etiology. This disease is chiefly encountered among young chil- 
dren, especially during the period of dentition. It occurs frequently 
among feeble children and cachectic persons, especially if they suffer 
with other disorders of the mouth and throat. It is often observed in 
connection with infective diseases, and with disorders of the alimentary 
canal. It occurs sometimes among women as a consequence of uterine 
disturbances, and during pregnancy or the period of lactation. Some- 
times the disease manifests an epidemic prevalence in certain localities, 
especially during warm or unsettled weather. It is probable that 
aphthous eruptions are of an infective origin, since the pyogenic 
staphylococci and numerous other bacteria exist in the inflammatory 
products. 

Pathological Anatomy and Symptoms. The characteristic ap- 
pearances in aphthous sore mouth consist in the development of round 
white flakes which appear upon the mucous membrane, and are sur- 
rounded by a red ring of injected bloodvessels. These deposits may 



3L0 DISEASES OF THE ALIMENTARY CANAL. 

be very minute, or they may reach the size of a split-pea. Sometimes 
the coalescence of several patches produces an irregular area of con- 
siderable size. If a tooth is cutting its way through the gum, an 
aphthous deposit is formed at the point of eruption. In other cases it 
occurs along the borders and tip of the tongue, upon its under surface, 
and along the fold between the lips and the gums. Aphthae may appear 
upon the roof of the mouth, about the uvula, and upon the tonsils, where 
they must not be mistaken for a diphtheritic membrane. 

Since aphthae frequently appear in successive crops, it is easy to 
trace their development. They are never vesicular, nor do they con- 
tain any accumulation of liquid. The aphthous flake consists of 
granular fibrin which contains a few embryonic cells entangled in its 
meshes. The exudations appear to be excited by the action of certain 
microorganisms which produce coagulative necrosis of the superficial 
epithelium, with subsequent exudation of fibrin and round cells. The 
exudation does not penetrate deeply into the mucous membrane, but 
seems to involve the superficial layer exclusively. The process of 
recovery is preceded by the exfoliation and discharge of the products 
of exudation, which leave behind an ulcerated surface that undergoes 
the process of cicatrization, and is usually healed in the course of ten 
days or two weeks. 

The disease is attended by no special danger, though nurslings fre- 
quently experience pain in taking the breast, and suffer in consequence 
from the effects of imperfect nutrition. 

Sometimes the orifices of the salivary ducts become obstructed by 
the development of aphthae, so that the glands become swelled and 
painful through retention of their contents. Immediate relief follows 
the introduction of a fine probe into the obstructed passage. 

Diagnosis. Apthae must be distinguished from (1) patches of coag- 
ulated milk which adhere to the mucous membrane, but are not sur- 
rounded by the reddened areola that characterizes an aphthous deposit ; 
(2) from ulcerative stomatitis, which is recognized by the occurrence of 
offensive breath, and by a tendency to hemorrhage from the ulcerated 
surfaces ; and (3) from herpes and thrush, which are characterized by 
the eruption of vesicles that contain a perceptible quantity of fluid. 
Thrush may also be diagnosticated by the discovery of its peculiar 
parasite. 

Treatment. The local use of a 2.5 per cent, solution of chlorate 
of potassium every two hours is all that is needed. 

Leucoplacia Oris. 

Pathological Anatomy. Leucoplacia oris is characterized by the 
appearance of light-gray or yellowish patches, usually upon the tongue, 
though sometimes upon the mucous membrane in any other part of the 
mouth. The patches are irregular, sometimes slightly elevated at their 
margins, and occasionally present a moderately indurated surface. They 
consist of epithelial cells, which are softened and swelled, and are 
heaped upon one another in an irregular fashion. The papilla? of the 



DISEASES OF THE MOUTH. 



311 



mucous membrane appear flattened, and the sub-epithelial layers are 
infiltrated with round cells. 

Symptoms, Diagnosis, and Prognosis. The symptoms are, for 
the most part, such as address themselves directly to the eye. Some- 
times there is a sensation of heat and tenderness in the affected parts. 
Gastric derangement is not uncommon. The disease may be readily 
differentiated from other oral disorders by the history of the case, and 
by microscopical examination of the exudation. 

Etiology. Leucoplacia is caused by irritation of the mucous mem- 
brane, arising from the use of tobacco and alcohol, or from the irrita- 
tion produced by decayed teeth, or as a result of disordered digestion, 
gout, and syphilis. It is, sometimes, associated with certain cutaneous 
disorders; e.g., psoriasis, lichen, eczema, icthyosis, and epithelioma. 
It is more frequently observed among men than among women, espe- 
cially during the period of active adult life. 

Treatment. Treatment must consist largely in the regulation of 
the habits and diet of the patient. For internal medication may be 
recommended arsenic (liquor potass, arsenit., 3 to 5 drops three times 
a day). The caustic application of chromic acid (a 20 per cent, solu- 
tion every three or four days) has been recommended. Galvano-cau- 
terization has also given favorable results. Nitrate of silver, tincture 
of iodine, and corrosive sublimate have been locally applied. The use 
of iodide of potassium is attended with considerable relief from suffer- 
ing, and the pain of cauterization may be greatly alleviated by the 
local application of cocaine. 

Thrush — Stomatomycosis Oidica. 

The occurrence of thrush upon the mucous membrane of the mouth 
is dependent upon the growth of a parasite, o'idium albicans. The 
disease usually occurs among children during the first few weeks of life, 



Fig. 




O'idium albicans, the vegetable parasite of muguet or thrush. (Reduced from Ch. Robin.) 



or in older patients who are the victims of other exhausting diseases. 
It is not uncommon among neglected infants who suffer from the want 
of proper nourishment and care. Artificially nourished children, who 



312 DISEASES OF THE ALIMENTARY/ CANAL. 

take their food from bottles that are imperfectly cleansed, are exceed- 
ingly liable to the disease. It may also be conveyed to the mouth of 
a healthy child by nursing at the breast of a mother who had previ- 
ously given suck to a diseased infant. The nipple may itself become 
the seat of the parasitic growth, by which nurslings may become 
infected. 

Symptoms. Thrush appears in the form of a thick, white layer 
upon the mucous membrane, and may be frequently discovered between 
the fungiform papillae, or in the neighborhood of the follicular glands 
of the mouth. These deposits gradually increase in size and thickness, 
and develop a gray, yellow, or brown color as the patches extend 
and become confluent. The exudation cannot be wiped off from the 
mucous surface, because it is beneath the superficial layer of epi- 
thelium. At a later period the epithelium gives way, and the products 
of exudation may then be removed, leaving behind a roughened sur- 
face. Microscopical examination discovers the presence of a great 
quantity of parasitic filaments and spores which are mixed with epi- 
thelial and embryonic cells. 

Thrush is by no means limited to the mucous membrane of the 
mouth. It may occupy any portion of the oral cavity, and it some- 
times exists in the pharynx, in the oesophagus, in the respiratory pas- 
sages, and in the alimentary canal. 

The duration of the disease is not uniformly defined. Recovery 
usually takes place in the course of ten days or two weeks. 

The development of thrush is frequently associated with an inflam- 
mation of the mucous membrane that occasions pain, and prevents 
nurslings from taking the breast. Sometimes they are also attacked by 
severe diarrhoea in consequence of fermentation and decomposition in 
the alimentary canal. 

Pathological Anatomy. The principal feature in the development 
of thrush consists in the invasion of the middle layers of the mucous 
membrane by a parasitic growth that causes atrophy of the invaded 
tissues. Sometimes the submucous tissue and the vascular structures 
are also invaded by the parasite. 

Diagnosis and Prognosis. Microscopical examination renders the 
diagnosis easy. The disease may be differentiated from aphthce by the 
absence of the areola which forms around the aphthous patch. Spots 
of coagulated milk resemble thrush in their superficial appearance, but 
the characteristic parasite is absent. The development of sarcince in 
the mouth may also be distinguished from thrush by the presence of the 
characteristic parasite. The prognosis is not always favorable, since the 
disease frequently occurs in association with other dangerous diseases. 

Treatment. Young children should always, after taking nourish- 
ment, have their mouths cleansed with a soft piece of linen that has 
been dipped in water. Nursing-bottles should be carefully washed and 
kept in a dish of salt water, when not in use. The nipple of the nurse 
should always be cleansed after each application of the child to the 
breast. The local treatment consists in the use of a 2.5 per cent, solu- 
tion of boric acid, every two hours. Young children who cannot rinse 
their own mouths may be treated bv swabbing the mucous membrane 



DISEASES OF THE SALIVARY GLANDS. 313 

with a soft piece of linen dipped in the solution, or, if they be very 
obstinate, the fluid may be thrown into the mouth with the aid of a 
small syringe. 

Oral Parasites. 

The number of parasitic organisms which may exist in the mouth is 
very large ; not far from one hundred different species and varieties 
have been discovered. Of these, a form identical with the pneumococcus 
is usually present. When the saliva in which it is contained is injected 
into the small animals of the laboratory, a fatal result is produced, with 
symptoms of septicaemia. Sarcina, Leptothrix buccalis, and various 
other microorganisms, are sometimes found in the mouth, where they 
undoubtedly excite numerous chronic, minor disorders. The well- 
known relation between parasitic microorganisms and the decay of the 
teeth is fully discussed in the writings of dental authors. 



CHAPTER II. 

DISEASES OF THE SALIVARY GLANDS. 

Salivation — Ptyalismus. 

Salivation is a term that indicates increase of the salivary secretion, 
which sometimes reaches a quantity sufficient to overflow the lips, causing 
great inconvenience to the patient. It is sometimes difficult to decide 
whether the amount of saliva is actually increased, or whether the 
mechanism for its retention and deglutition are defective, since the 
normal quantity varies within very wide limits. 

Increase of the salivary secretion is usually excited by reflex irrita- 
tion of the salivary glands. This may happen in connection with 
inflammatory diseases of the mouth, or as a consequence of the use of 
drugs which excite secretion, e. g., mercury, iodine, gold, silver, copper, 
lead, arsenic, jaborandi, physostigmine, nicotine, and digitalis. Spices, 
tobacco, and other substances that possess an irritant, acid, or acrid 
character, operate in the same way. Neuralgic affections of the cranial 
nerves, and excitation of the special senses, frequently react upon the 
salivary glands. In like manner diseases of the digestive organs, and 
sexual excitement, are frequently accompanied by salivation. Nervous 
and excitable persons frequently experience similar results as a con- 
sequence of cerebral exaltation or depression. Diseases of the medulla 
oblongata and pons Varolii are especially liable to be accompanied by 
profuse salivation. A considerable flow of saliva is sometimes observed 
in connection with certain infective diseases, especially at the period of 
crisis, when other secretions are exalted. 



3L± DISEASES OF THE ALIMENTARY CANAL. 

Symptoms. Sometimes the patient experiences a sensation as if 
water were flowing into his mouth. This is caused by the rapid afflux 
of saliva into the oral cavity. In certain cases a sensation of tender- 
ness and distention is experienced in the glands themselves. The 
patient must swallow frequently, or is obliged to expectorate the con- 
tents of his mouth, in order to avoid interruption during the act of 
articulation. The quantity may sometimes reach ten or twelve quarts 
in the course of twenty-four hours. The reaction of the fluid is variable, 
sometimes alkaline and sometimes acid. Ptyalin and sulphocyanide of 
potassium are frequently absent. 

Sleep is frequently disturbed by the copious discharge of saliva 
which saturates the pillow, or suffocates the patient, if it passes back- 
ward into the pharynx and larynx. The chin is erythematous from 
the constant overflow, and the stomach also becomes disordered in the 
same way. Not unfrequently the evidences of catarrhal inflammation 
of the stomach exist, especially among drunkards who vomit large 
quantities of saliva on arising in the morning. The renal secretion is 
also sometimes greatly increased. 

Transient cases speedily recover; but, in chronic cases, the patient 
gradually sinks into a cachectic condition, and, after a more or less 
protracted illness, dies from exhaustion, which is the result of the 
underlying disease by which profuse salivation was maintained. 

Diagnosis and Prognosis. Since salivation is only a symptom, 
one should never remain content with anything less than a diagnosis 
of the remote causes of the disorder, for upon their nature and curability 
will depend the prognosis. 

Treatment. If the cause of salivation can be removed, the symp- 
tom speedily disappears, but in cases of central origin or of a persistent 
nature, great relief may be obtained by the use of atropine, in doses of 
Y^o" °f a g ra i n ? two or three times a day. The drug may be used 
hypodermically with advantage. Opium has been given in small 
doses, J of a grain every two hours, with temporary benefit; but 
the risk of acquiring the opium habit must not be forgotten. The 
salivation of pregnancy is, sometimes, speedily relieved by the ad- 
ministration of iodide of potassium in 5 to 10 grain doses, three times 
a day. 

Diminution of the Salivary Secretion frequently results after the 
administration of atropine. It sometimes occurs during fright or 
mental excitement. Fever is generally attended with reduction of the 
secretion, and it forms one of the most disagreeable symptoms of 
diabetes and other diseases which are attended by an unusual discharge 
of urine. In all such cases, the remote cause must be ascertained in 
order to secure accurate indications for treatment. Distressing dry- 
ness of the mouth and tongue, such as may be frequently observed 
during the course of dangerous fevers, must be relieved by frequent 
cleansing of the mouth, the use of cooling drinks, and the application 
of vaseline to the lips and tongue. Sometimes advantage may be 
derived from the administration of pilocarpine or mercurials. 



DISEASES OF THE FAUCES AND PHARYNX. 315 



Fibrinous Inflammation of the Salivary Ducts — Sialodochitis 

Fibrinosa. 

Inflammation and obstruction of the salivary ducts with a fibrinous 
exudation has been occasionally observed. The salivary passages 
become distended and the glands are swelled and painful. The symp- 
toms are readily relieved by catheterization of the ducts, an operation 
which is followed by the escape of a purulent liquid that sometimes 
contains fibrinous plugs and parasitic microorganisms. Sometimes the 
passages become obstructed by the presence of calcareous masses (sali- 
vary calculi). 






CHAPTEK III. 

DISEASES OF THE FAUCES AND PHARYNX. 

Acute Catarrhal Inflammation of the Fauces and Pharynx — Angina 
et Pharyngitis Catarrhalis Acuta. 

Etiology. Acute pharyngeal catarrh is generally indicated by 
painful sensations that accompany the act of deglutition, as if the 
fauces were constricted. Hence the name Angina or Cynanche, which 
signifies constriction. The sensation is caused by a hypersesthetic 
condition of the inflamed mucous membrane, which, moreover, is some- 
what impeded in its functions by the inflammatory infiltration that has 
taken place. The inflammation may be circumscribed, or it may in- 
volve all of the soft parts of the fauces and pharyngeal cavity. 

Rheumatic angina occurs as a consequence of exposure to cold 
when the system is predisposed to rheumatism. Since that disease is 
dependent upon a peculiar infection, the effect of cold must be con- 
sidered as a predisposing cause for the invasion of the tissues by the 
infective agent. The particular parasite which constitutes the exciting 
cause of the disease has not been identified, but the general symptoms 
and the frequently epidemic appearance of the disease argue in favor 
of a parasitic origin. 

Rheumatic angina is very common among children, especially if they 
be delicately organized, and belong to families in which a predispo- 
sition exists. 

Traumatic angina is usually caused by the passage of sharp and irri- 
tating bodies into the pharynx. Inhalation of a dusty atmosphere, and 
misuse of the voice, are very liable to excite a chronic inflammation. 
It may also be excited in an acute form by swallowing hot or cold 
drinks, or by the inhalation of excessively heated air or irritating gases. 
Acids, alkalies, caustics, and various irritating drugs excite severe 
inflammation if allowed to enter the mouth and throat. 

Infective diseases, especially the exanthemata and syphilis, are fre- 
quently accompanied by angina. 



316 DISEASES OF THE ALIMENTARY CANAL. 

Finally, inflammation may invade the fauces and pharynx by a pro- 
cess of extension from adjacent centres of inflammation, such as occur 
in catarrhal diseases of the air- passages and gastric mucous membrane. 

Symptoms and Pathological Anatomy. Acute catarrhal inflam- 
mation of the fauces and pharynx frequently commences like other 
acute infective diseases. It is ushered in with chills and a high fever, 
which, among children, may be accompanied by convulsions. The 
patient complains of difficulty and pain in the act of deglutition. The 
fever subsides quite suddenly in the course of a few days, but there is 
considerable debility for a considerable time longer. There is often a 
notable disproportion between the general symptoms and the local in- 
flammation ; high fever may be associated with very slight visible 
change in the mucous surfaces. The spleen is frequently enlarged, 
and a herpetic eruption often appears about the mouth, as in other 
infective diseases. 

The act of swallowing is attended with some degree of pain ; yet the 
patient feels impelled to frequent efforts of that nature. The neck 
appears stiff, and the head is slightly inclined forward toward the side 
upon which the inflammation is most severe. Pain extends into the 
ear, and is felt behind the angle of the jaw. The voice is hoarse, and 
articulation becomes difficult and nasal, when the tonsils are enlarged. 
Sometimes the jaws become fixed so that the mouth cannot be opened 
without intense pain. The submaxillary lymph glands become enlarged 
and sensitive. The salivary glands secrete an excessive amount of saliva 
which is sometimes turbid, bloody, and offensive 

The intensity of the inflammation is variable, so that three forms of 
angina may be described : (1) Superficial catarrhal inflammation is 
characterized by redness and swelling of the mucous membranes. The 
color is sometimes uniformly diffused ; sometimes it is patchy, and 
hemorrhagic points may become visible. In certain cases the injected 
surfaces exhibit a bright-red color ; in others they are dark and purple. 
The amount of swelling is greatest when the submucous connective 
tissue is most loosely developed. For this reason, the uvula is frequently 
greatly tumefied and elongated, so that by its contact with the pharyn- 
geal surfaces retching and vomiting may be excited. If the tonsils are 
invaded (angina tonsillaris), they may be so greatly enlarged as to 
touch one another. Secretion is, at first, diminished ; but, at a later 
period, it is increased, and the inflamed surfaces are covered with, a 
muco-purulent exudation. The mucous follicles frequently participate 
in the inflammatory swelling, and project above the mucous surface. 
Their rupture is followed by local erosion and ulceration. Sometimes 
the perverted and exaggerated follicular secretion accumulates upon the 
surface, and may be mistaken by inexperienced observers for a diphthe- 
ritic deposit. 

(2) Phlegmonous angina is characterized by the extension of the 
inflammatory process to the submucous connective tissue, and by a pre- 
disposition to the occurrence of suppuration. It is ushered in with a 
very high fever, and the local swelling is greater than in the superficial 
variety of the disease. Suppuration leads to the formation of an ab- 
scess, which may break spontaneously, either into the oral cavity, or 



DISEASES OF THE FAUCES AND PHARYNX. 317 

externally through the tissues of the neck. Erosion of the carotid 
artery and fatal hemorrhage have thus been produced ; and cases are 
recorded in which pus has burrowed through the cervical connective 
tissues into the thorax. Death has been known to occur as a conse- 
quence of suffocation through obstruction of the air-passages after rup- 
ture of an abscess. In other cases oedema of the glottis has been 
developed, and has suddenly terminated life. Usually, however, the 
evacuation of pus is followed by speedy relief and rapid recovery. 

(3) Lacunar inflammation involves the tonsils alone. The tonsillar 
lacunae undergo inflammation, and are distended with a puriform secre- 
tion, which becomes caseated, and sometimes calcified, forming an offen- 
sive mass, varying from the size of a pinhead to that of a pea. It is 
composed of oil globules, crystals of cholesterine and of the fatty acids, 
associated with embryonic cells and numerous microorganisms. 

The duration of the disease as an acute inflammation occupies, ordi- 
narily, only a few days. The general symptoms are those of catarrhal 
fever. Many of the brief febrile attacks which occur among children 
are due to angina. The disease is liable to frequent relapses. The 
tonsils frequently become permanently enlarged, so that the posterior 
nares are obstructed, and the patient is obliged to breathe through the 
mouth. Sometimes respiration is thus very seriously impeded. Not 
unfrequently the Eustachian canal becomes involved in the inflammatory 
process, and otitis may result, with consequent deafness, noises in the 
ears, etc. The symptoms of gastric catarrh are very often observed in 
connection with pharyngeal inflammation. 

Diagnosis and Prognosis. The principal thing to avoid in the 
diagnosis of catarrhal angina is a confusion of its symptoms and visible 
signs with those which accompany diphtheria. The prognosis is very 
favorable, though the degeneration of the disease into a chronic form 
may be feared. 

Treatment. Prophylactic treatment is of great importance when 
a predisposition to angina exists. The patient should be warmly 
dressed, and, if possible, should reside in a dry and healthy locality 
where the air is pure and free from irritating qualities. An open-air 
life, with daily sponge-baths and plenty of friction with a flesh-brush, 
is important. 

The medicinal treatment of angina must be directed to the removal 
of its causes, and to the cure of the local disorder. Syphilitic and 
malarial or rheumatic cases require the specific treatment appropriate 
to those diseases. For local treatment the inhalation of vapor charged 
with five per cent, of chlorate of potassium, alum, or chloride of 
ammonium, is beneficial. Some recommend the insufflation of these 
remedies in the form of powder. An excellent gargle may be prepared 
with one drachm of tincture of capsicum to three ounces of water. 
Five grains of salicylic acid, with an effervescing powder in a half-glass 
of water, may be given every two hours with advantage, especially in 
rheumatic cases. Acute inflammation may sometimes be aborted by 
giving five grains of powdered gum guaiac with twenty grains of the 
bicarbonate of potassium in a half-glass of strong lemonade, every four 
hours. If high fever be present, antipyrine, acetanilide, or phenacetine 



318 DISEASES OF THE ALIMENTARY CAXAL. 

may be given as needed. If abscess form in the tonsils, it should be 
evacuated as early as possible. 

Chronic Catarrh of the Fauces and Pharynx — Angina Pharyngitis 
Catarrhalis Chronica. 

Etiology. Chronic catarrh of the fauces and pharynx may be 

either diffused or circumscribed. It usually occurs during the first 
fifteen or twenty years of active adult life. It is more frequent among 
men than among women, especially among those of a weakly and 
nervous organization. 

The disease sometimes results from a previous acute attack, or it 
may be developed gradually in a chronic form. Under all circum- 
stances it is dependent upon the same predisposing causes that lead to 
acute angina. It is. therefore, very common among professional people 
who are obliged to make excessive use of the voice, and among smokers 
and drunkards. It sometimes results as a consequence of circulatory 
obstruction in chronic heart and lung diseases. It may accompany 
chronic inflammation of the kidneys, syphilis, tuberculosis, gout, rheu- 
matism, and malarial cachexia. It may also result through the exten- 
sion of chronic inflammation from neighboring organs. 

Symptoms and Pathological Anatomy. A diffuse inflammation 
of the pharynx and fauces occasions a sensation of dryness and irrita- 
tion in the throat, especially on waking in the morning. The voice 
loses its smoothness and ease of articulation. The worst forms of the 
disease occur among old drunkards, who find themselves obliged, on 
arising, to clear their throats of a verv tough and adhesive mucus 
which can be discharged only with great difficulty, leading often to 
retching and vomiting. 

The tonsils frequently become very much enlarged, so that articula- 
tion acquires a disagreeably nasal character. The patient is obliged to 
breathe with the mouth open, and children thus acquire a peculiarly 
stupid expression of countenance. Sleep is frequently disturbed by 
the difficulty of breathing that is thus produced. A certain amount of 
deafness, ringing in the ears. etc.. frequently result from the implica- 
tion of the Eustachian tube in the inflammatory process. The uvula 
becomes enlarged, and often trails upon the back of the tongue, causing 
nausea and retching. 

In cases of chronic superficial catarrh the mucous surface is height- 
ened in color, and often exhibits varicosity of the veins. The mucous 
secretion is increased, and is sometimes tinged with blood, so that its 
expectoration alarms the patient with the fear of impending consump- 
tion. During sleep the exudation frequently becomes dry, and can 
be removed only by distressing efforts through retching and hawking, 
or even by vomiting, in the morning. The pharyngeal wall is fre- 
quently studded with minute elevations that mark the seat of the in-' 
flamed mucous glands. The intervening surface is dry and shining, or 
covered with a tenacious, muco-purulent secretion. 

Chronic parenchymatous catarrh is chiefly characterized by hyper- 
plasia of the tonsils and uvula. 



DISEASES OF THE (ESOPHAGUS. 319 

Chronic lacunar catarrh is characterized by the presence of yellow, 
offensive, caseated masses in the lacunae and follicles of the tonsils. 
The breath becomes exceedingly offensive; and patients are often 
alarmed by the expulsion of the lacunar masses which they suppose 
have originated in the lungs, and are actually pulmonary tubercles. 
This error has often rendered the lives of uninstructed patients very 
miserable. 

The duration of the disease is usually coincident with the term of 
life, by reason of the persistency of the habits and other causes by 
which it is perpetuated. Among children and among nervous people 
it sometimes excites paroxysms of laryngismus, or of asthma, through 
reflex influence. 

Treatment. The local treatment of the superficial form of the 
disease is the same that has been recommended for simple catarrhal 
affections of the oral mucous membrane. Benefit is sometimes derived 
from daily painting of the affected surface with tincture of iodine, or 
with a five per cent, solution of nitrate of silver, or with the glycerole 
of tannin, or with a fifteen per cent, solution of the liquor ferri sesqui- 
chloridi. The granular forms of pharyngitis are most successfully 
treated by galvano-cautery, which should be applied to each enlarged 
gland separately. Rheumatic cases are benefited by a residence at the 
various sulphur springs. Relief in such cases may also be obtained 
from sulphur in small doses. 

R . — Lac. sulphur., . gr. v. 

Potass, bitart, . . . . . . . . gr. j. 

Sacch. lact., gr. x. — M. 

S. — One such powder two or three times a day. 

Chronic hypertrophy of the tonsils or uvula requires their removal 
by surgical means. 

Among other parasites, Leptothrix buccalis sometimes invades the 
tonsils and the circumvalate papillae of the tongue. It may be recog- 
nized by the aid of the microscope, but for its extermination does not 
require any special treatment different from the ordinary methods above 
described. The same parasite sometimes proliferates in the air-passages, 
or in the oesophagus, where it may occasion considerable obstruction. 



CHAPTEE IY. 

DISEASES OF THE (ESOPHAGUS. 

Constriction of the (Esophagus — Stenosis (Esophagi. 

Etiology. The causes of oesophageal constriction are threefold : 
1. Intra- oesophageal constriction exists when foreign bodies have 
become impacted in the oesophagus in such a way as to diminish the 



320 DISEASES OF THE ALIMENTARY CANAL. 

calibre of the passage. Strange as ir may seem, the occurrence of this 
event has sometimes escaped recognition until examination of the body 
after death. Pedunculated tumors which project from the (esophageal 
wall sometimes produce constriction. 

2. Interstitial const r ~ ft), oesopl • exists when cancerous 
growths or cicatrized indurations have invaded the walls of the pass 
Among these last may be mentioned the consequences of swallowing 
corrosive acids, or alkalies, or scalding water, or the occurrence of 
ulcers that are dependent upon syphilitic or diphtheritic processes. 
Hound ulcers, similar to those which exist in the stomach, are some- 
times found in the lower portion of the oesophagus, and by their cica- 
trization may occasion stenosis. Abscesses and diverticula in the 
oesophageal wall produce the symptoms of constriction, and it some- 
times exists as a consequence of congenital :>/ in the develop- 
ment of the tube. Spasmodic strictures 0/ the oesophagus sometimes 
occur as a consequence of temporary spasm in the muscular coat of the 
passage. 

3. Extra-ces&phageal constriction may result from the enlargement 
or displacement, or degeneration, or malignant transformation of any 
of the structures and organs that lie in the immediate vicinity of 
the oesophageal canal. 

Pathological Axatomy. Constriction of the oesophagus occurs 
with increasing frequency as the stomach is approached. Multiple con- 
strictions are rare. The strictured portion is sometimes very short : 
sometimes it occupies a considerable extent of the passage. The whole 
circumference of the tube may be invaded, or a limited portion only 
may be subjected to contraction. Above the point of stenosis the 
:,agus is usually dilated, the muscular coat is hypertrophied, and 
the internal coat exhibits signs of catarrhal inflammation. Below the 
constriction the oesophageal walls are somewhat atrophied. 

Symptoms. The principal symptom of stenosis consists in the evi- 
dence of difficulty in the act of deglutition. This is gradually devel- 
oped, unless the cause of constriction has become suddenly operative, as 
when a foreign body becomes impacted in the passage. There is com- 
plaint of discomfort and obstruction in the act of swallowing, which may 
be localized at any point in the course of the oesophagus, though the 
sensation may afford no accurate indication of the precise situation of 
the constriction. Sometimes, especially in the case of a tight stricture, 
the act of swallowing food is followed by a sensation of suffocation, in 
e-nsequence of compression of the respiratory passages by the dis- 
tended oesophagus. 

Food that has been swallowed is soon regurgitated. If the oesoph- 
agus has become pouched above the constriction, or if the point of 
stenosis is situated near the stomach, regurgitation may be delayed for 
some hours. Severe hiccough has been observed when the constriction 
was situated below the diaphragm. 

A- the disease progresses the patient finds himself compelled to 
restrict his diet to liquids. Finally, a sufficient supply of nutriment 
can be no longer swallowed, and emaciation and exhaustion inevitably 
lead to a fatal termination. 



DISEASES OF THE (ESOPHAGUS. 321 

In order to ascertain the situation and amount of constriction, it is 
necessary to resort to exploration with the aid of the oesophageal 
sound. For this purpose an olive-pointed bougie may be carefully 
introduced into the oesophagus, and gently passed downward until the 
seat of obstruction is reached. In order to effect the introduction with 
ease and safety, the physician should be assured that the sound will 
not break and that the point is firmly attached. Placing a large cork 
between the back teeth of the patient, the tongue should be depressed 
with the fore- and middle-fingers of the left hand, while with the right 
hand the sound is cautiously introduced along the posterior wall of the 
pharynx. Great disturbance often follows this proceeding, but, with a 
little practice, a successful result may be reached. In very sensitive 
conditions the pharynx may be advantageously painted with a ten per 
cent, solution of cocaine before the operation is undertaken, or a scruple 
of potassium bromide may be taken half an hour before the passage of 
the sound. 

Auscultation of the oesophagus during the act of swallowing a liquid, 
sometimes gives valuable information in the absence of a sound. The 
passage of the fluid through a narrow stricture causes gurgling sounds 
that are rendered audible by auscultation along the left side of the 
trachea in the neck, and along the left side of the spinal column in the 
back, as low as the eighth or ninth rib. A method of investigating 
the oesophagus by percussion has been proposed. For this purpose 
the patient is made to swallow a teaspoonful of the bicarbonate of 
sodium in a small quantity of water, followed by a similar quantity of 
tartaric acid. The effervescence that follows causes distention of that 
part of the oesophagus which lies above the stricture, and its limits 
may be then determined by percussion. The discomfort that is expe- 
rienced by the patient during such an operation generally contra-indi- 
cates its employment. 

Temporary improvement in the condition of a strictured oesophagus 
is sometimes observed when stenosis has been produced by cancerous 
growths, or by adjacent glandular enlargements which are subject to 
variation in size. 

A fatal termination generally results from starvation after complete 
occlusion of the oesophagus. Sometimes perforation of the oesophagus 
occurs, by which a communication with neighboring cavities is effected, 
with a subsequent fatal result. 

Prognosis. The prognosis is dependent upon the cause of oesophageal 
stricture, and upon the rapidity of the constrictive processes. 

Treatment. The treatment must be directed against the under- 
lying causes of stricture, and must also attempt the relief of the con- 
striction. The local treatment of the disease is fully discussed in the 
manuals of surgery. It consists chiefly in the attempt to effect a 
gradual dilatation of the stricture by the daily introduction of bougies. 
For this purpose catgut sounds or dilators of laminaria may be intro- 
duced. These, through their expansion under the influence of moist- 
ure, may be relied upon to produce a favorable result so long as the 
stricture is permeable. Cancerous constrictions may be thus greatly 
relieved, since their softened tissues yield readily to pressure. The 

21 



322 DISEASES OF THE ALIMENTARY CANAL. 

relief of complete occlusion of the oesophagus has been attempted by 
the operation of gastrotomy, but the results are exceedingly unfavorable. 
(Esophageal constriction sooner or later necessitates the alimentation 
of the patient through the rectum. When liquids can be no longer 
swallowed or introduced through an oesophageal catheter into the 
stomach, it becomes necessary to have recourse to nutritious injections. 
For this purpose peptonic preparations may be given in beef-tea, mixed 
with an equal quantity of milk, and thickened with a little starch. 
The fluid should be introduced, in a quantity not exceeding four 
ounces at a time, through the aid of a funnel and rectal tube, rather 
than by the use of a syringe, which is liable to irritate the bowel and 
to excite speedy evacuation of its contents. A most valuable form of 
nutriment may be prepared by mixing one part of tepid water with 
three parts of minced meat and one part of similarly prepared pancreas 
that has been freed from fat. In this way pancreatic digestion is 
secured and a fair degree of nourishment is accomplished. 

Cancer of the (Esophagus — Carcinoma (Esophagi. 

Pathological Anatomy. (Esophageal cancer is almost always of 
primary origin and epithelial character. It is generally situated in 
the lower third of the passage. Its favorite seats are immediately 
behind the cricoid cartilage or the left bronchus, and at the cardiac 
extremity of the oesophagus. It may develop as an isolated mass or it 
may embrace the whole circumference of the food-pipe. The oesopha- 
geal wall becomes considerably thickened and dilatation of the passage 
sometimes takes place above the point of stricture. The adjacent 
lymph glands become infiltrated with cancer, especially in the medi- 
astinal space, and especially in the vicinity of the trachea and bronchi. 
The cancerous masses frequently break down and ulcerate, and thus a 
communication may be established between the oesophagus and any of 
the neighboring cavities. The disease, moreover, may propagate itself 
into any of the structures in its vicinity. Thus the vertebral canal and 
the thoracic viscera may be invaded, or the disease may be disseminated 
among still more distant organs. 

Etiology. (Esophageal cancer occurs more frequently among men 
after the middle period of life. It may be directly excited by injuries 
or corrosion of the oesophagus, or by immoderate use of alcohol, and by 
chronic disease of the stomach. 

Symptoms. The invasion of the oesophagus by a carcinomatous 
growth is very gradual. The occurrence of stenosis often affords the 
first symptom of the disease. This is frequently attended by great 
pain that is sometimes independent of the act of deglutition. It is 
generally referred to the lower portion of the passage, and may occur 
only during the night. Sometimes it extends along the intercostal 
spaces into the extremities. Frequently the recurrent nerves experi- 
ence paralysis, so that the voice becomes affected. Laryngoscopy 
inspection readily reveals the paralytic condition of the laryngeal 
muscles. 

When the upper portion of the oesophagus is the seat of a tumor, it 



DISEASES OF THE (ESOPHAGUS. 323 

may be sometimes detected by pressure in the neck. When situated 
lower down it is necessary to resort to the use of the oesophageal sound. 
In this way particles of cancerous tissue may frequently be brought to 
view. The act of regurgitation also may bring up similar particles 
which possess great diagnostic value. 

As the disease advances the principal symptoms are those of oesopha- 
geal constriction. The patient suffers with hunger and thirst, but the 
stomach is in great measure deprived of its digestive function through 
the absence of free hydrochloric acid from the gastric juice. The 
bowels are usually constipated, and the urine contains indican, which 
may be readily discovered by the reaction of the urine with an equal 
quantity of hydrochloric acid and a few drops of a fresh solution of 
hypochlorite of calcium, which develops a dark red or indigo color. 

The average duration of oesophageal cancer is about thirteen months. 
A fatal termination results from starvation, or from hemorrhage, or from 
oesophageal perforation and subsequent intra-thoracic disease. Some- 
times the vertebral canal is penetrated, and paralysis follows. Not 
unfrequently fever and pyaemia result from purulent absorption. In 
certain cases the symptoms of asthma or of angina pectoris may occur. 
Thrombosis and oedema are not uncommon. 

Prognosis and Treatment. The prognosis is unfavorable. The 
treatment consists principally in attention to the alimentation of the 
patient, and to the relief of pain with narcotic remedies. Daily intro- 
duction of the sound frequently postpones the occurrence of complete 
occlusion. 

Dilatation of the (Esophagus. 

Dilatation of the oesophagus may occur as a primary congenital con- 
dition which involves either the whole length or a limited segment of 
the passage. Secondary dilatation sometimes occurs when a stricture 
exists in the course of the oesophagus. It has been observed occasion- 
ally after constriction of the pylorus. The muscular layer may present 
various modifications of structure, or may be completely absent at par- 
ticular points. The mucous surface of the oesophagus exhibits a con- 
dition of chronic catarrh. The state of dilatation is attended with 
difficulty in deglutition and with regurgitation of the food, which, on 
examination, appears macerated, and presents an alkaline or neutral 
reaction instead of the acid reaction and evidences of partial digestion 
which are apparent if the mass had previously reached the stomach. 
The starchy constituents of the food are transformed into sugar by the 
action of the saliva that has been swallowed, and they exhale a sweetish 
odor, unless that is overpowered by the stench of putrefaction which 
frequently exists. 

Secondary dilatation of the oesophagus is ordinarily masked by the 
usual symptoms of oesophageal constriction. 

Sacculation of the (Esophagus — Diverticulum (Esophagi. 

(Esophageal diverticula exist under two forms : 

1. Sacculation of the oesophagus (pulsion-diverticulum) is a rare 
occurrence. It usually exists near the point of transition from the 



B24 i-: = ZA5Z= :z rzz ,::::i:::,?: :a>"az. 

pharynx into the oesophagus, and involve? the posterior wall of the 
passage between the oesophagus and the spinal column. Large poaches 
frequently bulge out upon one side or the other* of the larynx and 
trachea. Their dimensions may vary from the size of a small thimble 
to that of a pint flask. Their mucous lining is usually in a condition 
of chronic inflammation, and may exhibit multiple erosions. Some- 
times the muscular layer is defieient- 

The disease occurs most frequently among men after the middle 
T-e-t:: : :: ~::-r I: := .-: .r ... " : ::::ri:::;' r-rliv - : :l n^- :i:«: 
in certain cases, occasioning a deficiency of muscular resistance in 
the oesophageal walL and a consequent protrusion of the remaining 
layers S e :le changes may also fi r« i :_t none resnll 

I_t ; "_ ::zi= :: ::: :zz~y-i =-: : ::."::: :l :: :_t ri:z'-\z~i -'-- z ■ - 
-;;_'_- ItTtI:; t . ". J: : '. :i " ".:: :.: is ::>: :_ : iZ\LZ~: :- ~::ln tL-e- 
from which they can be frequently pressed back into the oesophagus. 
i-;\ . zizz-iz-2 -:/_"- :_ -. . z.-. .:>::::_:: z.~ :LtSt : : i-esses. As 
the sac enlarges, neighboring organs and stractures nmlexg ledovB 

: : _ rress::n. ■whi:i _ ~ ::::-:::. ::.::: :::l. _±::.t r-s:::: : 

Eyniiizis :: isil-zii Ilizz.zz::zz::z. :: i-i::~ :~- : ~_ . :~t:.s:~t 
food follows several hours after its deglutition. Sometimes so large a 
quantity of nourishment is thus intercepted that the patient is in danger 
of starvation. The introducrion of a sound n sometimes rllowed by 
i:s t:.:::l;t :.. -.— : — .:_:_ :_t z:~:l Ir. i-E-r: .:_ : ^ . _t. 
sound may be at the same time carried onward through the oesophagus 

The treatment of oesophageal sacculation does not differ essentially 

:::_ :'_ :.: -*'zl:'z. is r-rL'iiiri ir. iiliTiiizi. :r ::hs:t:::::l :: :le es:ii- 

_ Diverticula may be formed in connection with the oesophag ■ 
rLr 7-:: 'Is'im-- :: liesiins :t:~ttL its tIztt... :*. - .' . : :-r . . - 

boring bronchial or tracheal lymph glands which have undergone peri- 
adenitic inflammation (taction-divertieula). Subsequent contraction 
of the inflamed tissues causes traction upon the adherent wall, and thus 
a diverticulum may be formed. Similar adhesions and subsequent con- 
::. :: :_ :zz ::iLr:r:: ~:zz. il~ ::::: : : z:-z.: ::ss ; T - : : zzi.t :"_t >-i: 
resulz The pouch which is thus formed rarely exceeds half an inch in 
depth; consequer.:. - . il seldom produces any notable symptoms, and 
the principal danger which accompanies its existence lies in the tendency 
to perforation of the oesophageal wall through the diverticulum. In 
this way a communication may be established between the oesophagus 
and any of the neighboring cavities. 

rrhal Inflammation of the (Esophagus — GEsophagitis Catarrhalis. 

Etiology. Catarrhal inflammation may invade the oesophagus as a 
consequence either of mechanical injuries, or by reason of the passage 
of liquids that are too hot or too cold, or which possess a cor: 
character. Chronic inflammation of the pharynx or of the stomach, 
and inflammation in other neighboring structures, may be propagated 
by continuity to the oesophagus. It not unfrequently accompanies acute 



DISEASES OF THE (ESOPHAGUS. 325 

infective diseases ; and it may be observed as a consequence of circulatory 
obstruction in the course of chronic diseases of the organs of circulation 
and respiration. 

Pathological Anatomy. Catarrhal inflammation of the oesophagus 
may exist as an acute or as a chronic disease. It may be either diffuse 
or circumscribed. Acute catarrh is indicated by softening and exfolia- 
tion of the epithelium, often accompanied by swelling and inflammation 
of the mucous follicles. The mucous surface is, at first, dry, but after- 
ward it is covered with a muco-purulent discharge. In severe cases it 
may become actually eroded or ulcerated. Suppuration and gangrene 
are rare events. 

In chronic catarrhal inflammation of the oesophagus the mucous 
membrane appears thickened and of a dark-red color. It is frequently 
ulcerated, and the secretions are tenacious and muco-purulent. Papil- 
lary growths and polypi sometimes result from the chronic inflammatory 
process. 

Symptoms and Diagnosis. There is usually complaint of an ill- 
defined sensation of pressure, or of actual burning and smarting, along 
the course of the oesophagus, which is referred sometimes to the neck, 
or to the space between the shoulder-blades, or beneath the sternum, or 
to the epigastrium. Deglutition is usually painful, and the various 
movements of the neck and body often excite a sensation of distress. 
Deglutition may be not only painful, but may become the occasion of 
reflex spasms in the oesophagus or in the respiratory muscles, producing 
a sensation of suffocation which, occasionally, results in convulsions. 
Sometimes the alimentary mass is regurgitated, and presents a slimy 
covering that is tinged with blood and mixed with pus. The introduc- 
tion of a sound is usually followed by similar consequences. 

In certain cases, as after swallowing acid or caustic liquids, the entire 
epithelial layer of the mucous membrane may become detached, and be 
discharged in the form of a continuous tube. In such cases the sub- 
mucous tissues are usually involved, and severe constriction may follow 
the process of cicatrization. 

Treatment. Pain must be relieved by the use of morphine and 
atropine, hypodermically. Ice may be given in small pieces, as desired. 
The food should consist of iced milk ; if necessary, nutritious injections 
may be administered. Chronic catarrh of the oesophagus may be locally 
treated by the use of a probang covered with an astringent salve. 
(Rt. Acid, tannic. 1.0 : vaselin. 10.0. 1^. Argent, nitrat. 1.0 : vaselin. 
10.0.) 

Phlegmonous Inflammation of the (Esophagus — Oesophagitis 
Phlegmonosa. 

This very rare disease is characterized by suppuration in the sub- 
mucous connective tissue of the oesophagus, a process which may result 
in the formation of a circumscribed abscess. During the development 
of the disease the lumen of the oesophagus may be somewhat constricted. 
Rupture of the abscess may be followed by regurgitation of pus, or by 
its passage downward into the stomach. Cicatrization may follow, or 
the cavity of the abscess may become lined with epithelium, remaining 



iiszaszs ■:•? :hz iiivzyiAET :avai 

in the form of a pouch within the oesophageal wall. The disease may 
occur in connection with various infecti.r - - ; suppurative pro- 
- in the neighboring structures. The symptoms are quite obscure, 
and the treatment must be conducted in accordance with general prin- 
ciples. In feet, it usually is merged in the treatment of the general 
condition of the patient. 

Hemorrhage from the (Esophagus may occur as — juence of 

injuries or woun Is which communicate with large bk I vessels. It can 
occur as a consequence of ulcerative processes, or from varicose veins, 
such as may exist in connection with cirrhosis of the liver, 
of which the return of blood through the inferior oesophageal 
which ana: >mose with the coronary vessels : the stomach, is retarded. 

Softening of the (Esophagus, chiefly implicating the inferior portion 
of the canal, has been observed. It is generally associate L with similar 
conditions in the stomach. It can hardly be recognized with any d 2 
of probability during life. 

Spontaneous Rupture of the (Esophagus is a very rare event. 
Scarcely twenty cases are recorded. It usually occurs in men of intem- 
perate habits and advanced life. The event is sudden, and is attended 
with severe pain between the shoulders. .Symptoms off collapse and 
subcutaneous emphysema are speedily developed, and death follows in 
the course of a few hours. 

Paralysis of the (Esophagus occurs usually as a consequence of Us- 
ages >f the brain and cervical portion of the spinal c : r 1 It has been 

-red as a consequence of compression of both pneumogastric r. e 
Diphtheria, syphilis, blood-poisoning, and alcoholism have been known 
ise the disorder. Occasionally it happens as a transient event in 
:eria. The treatment must be regulated by consideration of the 
causes of the disease. Electr: : :: ept in cases which are 

dependent upon deep-seated and incurable degenerations of the nervous 
cen:: a 

Spasm of the (Esophagus is a neurosis that may occur in connection 
with hysteria and other functional nervous derangements. It forms a 
distr _ mptom in cases of tetanus and hydrophobia. In many 
instances it occurs as a transient phenomenon excite*! by reflex pro- 
is dependent upon disorders of the stomach, sexual appara: 
other irritable portions of the body. Certain poisons, like belladonna 
and stramonium, and the toxaemia which characterizes the arthritic 
-:: ration, may produce the spasm. I uncommonly developed 

as an incident in the course of oesophageal examination with the sound. 
In excitable persons it often occurs in variable degree daring the act 
wallowing food or drink. It ordinarily subsides urse of a 

few minutes, unless occasioned by poisoning or by dangerous diseases. 
If pain be unusually severe, it may necessitate the administration of 
narcotics. The galvanic current, in association with tonic and elimina- 
oreatment, is useful in many eas - 



DISEASES OF THE STOMACH. 327 



CHAPTER Y. 

DISEASES OF THE STOMACH. 

Gastric Hemorrhage — Haemorrhagia Ventriculi. 

Etiology. Gastric hemorrhage may occur as a consequence of 
wounds or injuries of the internal surface of the organ. Caustic 
poisons, corrosive alkalies, and concentrated acids frequently occasion 
its incidence. It frequently occurs in connection with ulcerative pro- 
cesses that are dependent upon round ulcer of the stomach, cancer, or 
severe gastritis. 

Vascular disorders, and diseases involving the gastric bloodvessels 
may occasion hemorrhage. Thus it may follow any condition of the 
liver by which is produced an obstruction in the course of the portal 
circulation. 

Hysteria and injuries of the central nervous system are sometimes 
followed by gastric hemorrhage as a result of vasomotor disturbances. 

Many of the infective diseases are accompanied by gastric hemor- 
rhage. It is not uncommon in severe forms of malarial infection. 

Hemorrhagic diseases, such as scurvy, purpura, and haemophilia may 
also occasion hemorrhage into the cavity of the stomach. Diseases of 
the liver and kidneys are often attended by changes in the walls of the 
bloodvessels which favor the occurrence of hemorrhage. It may also 
occur by substitution in place of habitual discharges of blood, such as 
may be witnessed in suppression of menstruation, or upon the drying 
up of bleeding piles. Perforation of the walls of the stomach by 
neighboring abscesses or aneurism is generally attended by more or 
less hemorrhage. 

Gastric hemorrhage occurs more frequently among women than 
among men, in consequence of their greater proclivity to ulcers of the 
stomach. It is most common between the age of puberty and the turn 
of life. 

Pathological Anatomy. After death from gastric hemorrhage the 
stomach is sometimes found distended with clotted blood. If the amount 
of hemorrhage has been moderate, small clots only, or liquids which 
resemble coffee-grounds or chocolate, occupy the cavity. The mucous 
membrane appears pale, and sometimes the ruptured vessels can be dis- 
covered ; but frequently no definite source for the discharge of blood 
can be detected (Capillary hemorrhage). Blood is frequently found in 
the intestines, and, if vomiting has preceded death, it is sometimes seen 
in the air-passages also. 

Symptoms. Slight hemorrhage may occur without exciting any 
special symptoms, but any considerable amount of blood will be either 
vomited or voided by stool. The feces are black, sometimes very hard, 
or semi-solid and exceedinglv offensive. Vomiting brings to light dark 



328 DISEASES OF THE ALIMENTARY CANAL. 

clotted blood, or, if the hemorrhage be excessive in amount, fresh arte- 
rial blood may appear. The contents of the stomach are highly acid, 
and are mixed with the remains of food and the debris of ulceration or 
malignant disease, if such processes have invaded the gastric walls. 
The patient complains of warmth and distention in the stomach. 
Sometimes the gush of blood can actually be felt. This is soon fol- 
lowed by nausea, vomiting, and in severe cases by the symptoms of 
collapse. If the larynx and trachea become obstructed by the entrance 
of blood-clots during the act of vomiting, asphyxia will follow. In 
certain instances, however, fatal hemorrhage may exist without either 
vomiting or the passage of blood from the bowels. 

After severe gastric hemorrhage the patient remains pallid and 
debilitated for a considerable period of time. Relapses may occur. 
An cedematous condition of the face and extremities is not uncommon. 
The symptoms of anaemia are manifested in the condition of the circu- 
lation, by which cardiac and venous murmurs are developed. The 
blood exhibits a deficiency of red corpuscles, and sometimes there is an 
excessive production of white blood-corpuscles. The breath becomes 
offensive, and indigestion forms a prominent symptom. Evidences of 
general failure of nutrition exist, sometimes characterized bv exfoliation 
of the epidermis, falling of the hair, or albuminuria. Occasionally, 
amaurosis occurs within a few days after gastric hemorrhage : its cause 
is unknown. 

Diagnosis. Gastric hemorrhage may be suspected in cases of death 
rapidly following sudden collapse, preceded by symptoms of gastric dis- 
ease, even though no considerable escape of blood has been observed. 
The occurrence of bloody stools is by itself no indication of gastric 
hemorrhage, since it may result from intestinal diseases. Blackened 
feces must not be accepted as evidence of hemorrhage unless the pres- 
ence of iron, or bismuth, or other substances by which the feces may 
be darkened, can be excluded. Vomiting of blood cannot be received 
as evidence of gastric hemorrhage unless it be possible to exclude pul- 
monary haemoptysis and hemorrhages from the mouth, nose, or other cavi- 
ties whence blood may have found its way downward into the stomach. 

The possibility of deception in cases of malingering or hysteria must 
not be forgotten. Certain articles of food or drink mav sometimes 
produce a discoloration of vomited matter which closely resembles the 
appearances that are presented by more or less altered blood. New- 
born children sometimes fill their mouths and discolor the contents of 
their stomachs with blood that has been sucked from the breast of the 
mother. 

Prognosis. The prognosis is usually favorable so far as immediate 
consequences are concerned, but relapses and remote consequences are 
dependent upon the underlying causes of hemorrhage. Sudden death 
occurs only when a large vessel or aneurism is ruptured. 

TREATMENT. The indications for treatment are threefold: to pre- 
vent hemorrhage, if it be threatened : to arrest actual hemorrhage : and 
to obviate its evil consequences. 

The first indication requires attention to those diseases by which 
2 stric hemorrhage may be produced. 



DISEASES OF THE STOMACH. 329 

The occurrence of actual hemorrhage demands perfect repose of 
mind and body on the part of the patient. Small pieces of ice may be 
swallowed ; an ice-bag should be laid over the pit of the stomach, and 
fifteen minims of ergotine may be injected hypodermically into the 
subcutaneous tissue of the epigastrium. Syncope may be relieved by 
depressing the head of the patient and by the use of stimulants, e. g., 
alcohol, ammonia, ether, and camphor (three grains dissolved in half a 
drachm of almond oil, hypodermically). After the cessation of vomit- 
ing a lead and opium pill may be given every three or four hours, or 
ten drops of aromatic sulphuric acid, in half a glass of water, may be 
given at similar intervals. Alum whey is also an excellent styptic, and 
may be given in doses of a wineglassful every fifteen or twenty minutes. 
Capillary hemorrhage is sometimes benefited by the administration of 
oil of turpentine in five-drop doses, to be repeated every hour. Hemor- 
rhage that is dependent upon malarial infection requires large doses of 
quinine. 

Desperate cases may be treated by transfusion of blood. After the 
apparent cessation of hemorrhage, if the bowels seem to be distended 
and uneasy, they should be evacuated by the administration of a pow- 
der containing five grains each of calomel, jalap, and the bicarbonate 
of sodium. 

The diet must consist at first of iced milk. The return to ordinary 
food must be considerably delayed and gradually effected. Subsequent 
anseinia and debility will be the occasion for great caution in the admin- 
istration of food and drugs, since iron cannot be employed if acute 
gastric inflammation exist. 

Acute Gastric Catarrh — Gastritis Catarrhalis Acuta. 

Etiology. Acute catarrhal inflammation of the stomach is gener- 
ally caused by errors of diet. Food which is either too hot or too cold, 
or excessive in quantity, or of a coarse and irritating character, is liable 
to excite gastric inflammation. In like manner, spices, acids, strong 
liquors, unwholesome wine or beer, and impure water may excite 
inflammation. Unusual articles of food, green fruit, seeds, stones, 
decomposing cheese and other substances which are undergoing fer- 
mentation or putrefaction, may also excite the disease. In this way 
tainted fish, mussels, oysters, ice-cream, milk, canned or compressed 
meats, sausages, old cheese, etc., may excite violent gastritis by the 
ptomaines that have been formed in their substance through bacterial 
action. Wounds and injuries involving the stomach, and neighboring 
inflammations, are frequent causes of gastritis. It is frequently ob- 
served in cachectic and chlorotic patients, and among the victims of 
gout and uraemia. Diseases of the thoracic organs and of the liver 
which hinder the circulation of blood, and states of nervous excitement 
which disturb the processes of secretion and nutrition, are all liable to 
be followed by catarrhal inflammation of the stomach. 

Acute gastritis sometimes follows excessive exposure to cold ; and it 
is an almost universal complication of infective diseases, and of disor- 
ders of the naso-phargngeal and oral cavities. Diseases of the respir- 



330 DISEASES OF THE ALIMENTARY CANAL. 

atory organs which are accompanied by infective discharges frequently 
originate the disease if the sputa are swallowed. 

Pathological Anatomy. Catarrhal inflammation of the stomach 
principally affects the pyloric extremity of the organ. The mucous 
membrane is swelled, softened, reddened, and covered with tenacious 
mucus that is somewhat turbid, or even streaked with blood. The 
capillary bloodvessels are dilated, and submucous extravasations are 
frequently visible. 

Symptoms and Diagnosis. Acute gastric catarrh causes loss of 
appetite, thirst, nausea, and frequently vomiting. At first the contents 
of the stomach are discharged, usually in an undigested condition and 
very acid in consequence of the presence of lactic and butyric acids. 
Free hydrochloric acid is absent. If the stomach has been thus evacu- 
ated, persistent vomiting brings up a tenacious viscid mucus that is 
sometimes streaked with blood. After a time this assumes a yellowish 
or green color in consequence of the regurgitation of bile into the 
stomach. Sometimes there is a noisy hiccough and eructation of gases 
or acrid liquids which sometimes exhale an acid or sulphurous 
A sensation of distention and of tenderness on pressure is often re- 
ferred to the epigastrium. Deglutition of food under such circum- 
stances is frequently followed by pain that is referred to the inter- 
scapular region, or is felt in the epigastrium. The t is very 
much coated, the breath is offensive, and a herpetic eruption sometimes 
appears upon the lips ; the bowels are generally constipated, unless 
they also participate in the inflammatory excitement. The 
diminished and concentrated. 

The nervous system exhibits evidences of considerable disturbance. 
Headache, throbbing in the temples, depression of spirits, inability to 
concentrate the attention, and indisposition to mental exertion are com- 
monly observed. Sometimes vertigo occurs. 

Fever is usually quite moderate, except in the cases of children, 
who frequently exhibit the phenomena of high fever, sometimes com- 
plicated with convulsions. Severe febrile symptoms suggest the r usa- 
bility of typhoid fever, but the sudden rise of temperature and the 
early termination of febrile symptoms are characteristic of catarrhal 
fever rather than of typhoid. 

Pro rNOSlS. The duration of acute gastric catarrh seldom exceeds 
a week, or two weeks at the longest Relapses are not uncommon, and 
they predispose the patient to chronic catarrhal inflammation ; other- 
gnosis is favorable. 

Treatment. If the stomach be overloaded, it should be evacuated 
by means of a hypodermic injection of apomorphine. or by th< 
ministration of an emetic (pnlv. ipecac, zinc, sulph.. aa 3j. Acidity 
and gaseous distention of the stomach may be relieved by alkaline 
drinks (a teaspoonful of bicarbonate of sodium in a glass of w 
This should be followed by a powder containing five grains each of 
calomel and jalap : or by a teaspoonful of calcined magnesia stirred 
into a glass of water: or by two or three teaspoonfuls of comp 

ice powder in water. A large, warm flaxseed-meal poultice should 
the entire surface of the abdomen. Pain mav be relieved by the 



DISEASES OF THE STOMACH. 331 

hypodermic use of morphine and atropine. The diet should consist of 
milk and lime-water, and should be very gradually restored to its 
ordinary quantity and quality. During convalescence dilute hydro- 
chloric acid may be given in ten-drop doses, in a cup of tepid water, 
an hour after each meal. 

Chronic Gastric Catarrh — Gastritis Catarrhalis Chronica. 

Etiology. Chronic gastric catarrh is usually developed as a con- 
sequence of previous acute inflammation. It is exceedingly common 
among drunkards. It is frequently observed among people who eat 
hastily and at irregular times, without proper selection of their diet. 
Coarse and imperfectly masticated articles of food act as exciting 
causes of the affection. It is also observed in connection with ulcer- 
ative and cancerous diseases of the stomach ; or as a consequence of 
diseases in other organs by which the circulation of blood is retarded. 
It is often witnessed among the victims of cachexia, anaemia, and 
chronic diseases. The male sex affords the largest number of patients. 

Pathological Axatomy. The pyloric portion of the stomach is 
the favorite seat of chronic catarrhal inflammation. The mucous mem- 
brane is of a dark-red or gray color, the bloodvessels are distended, and 
superficial extravasations and erosions are visible. The connective 
tissue contains red blood-corpuscles and blood pigment. There is con- 
siderable swelling of the mucous membrane ; its surface is covered with 
tenacious mucous, which may be tinged with blood and may contain pus 
corpuscles. The gastric glands are compressed, and their cellular 
structure exhibits evidence of degeneration and atrophy. The inter- 
glandular spaces are infiltrated with round cells. Mucous secretion is 
relatively increased. The connective tissue is increased so that the 
gastric wall appears considerably firmer and thicker than in health, and 
the peptic glands are correspondingly atrophied. The submucous and 
the muscular layers of the gastric wall participate in the inflammatory 
process, and the external serous investment may also be thickened and 
inflamed. 

In old cases of long standing the mucous surface of the stomach 
appears uneven and warty, somewhat like a wound that is covered with 
abundant granulations. This is caused by excessive proliferation in the 
submucous tissue. The gastric wall is thus thickened and transformed 
into a firm and resisting mass which sometimes, on incision, creaks like 
leather that is cut with a dull knife. 

Symptoms. The symptoms of chronic catarrhal gastritis differ 
chiefly from those of the acute form by their lesser degree of severity. 
There is loss of appetite, a sensation of tenderness and distention in 
the region of the stomach; sometimes there are paroxysms of excessive 
hunger, and a longing for spices and pickles ; thirst is usually increased. 
Eructation of gaseous and acrid liquids is a very common and disa - 
greeable symptom. Vomiting does not occur as frequently as in acute 
gastritis, though drunkards frequently retch and eructate considerable 
quantities of mucus and saliva on arising in the morning. The gastric 
contents not unfrequently contain bile and specimens of the yeast 




332 DISEASES OF THE ALIMENTARY CANAL. 

fungus or sarcina. The tongue may be either completely clean and 
healthy, or it may be covered with a thick brown coat. In cases accom- 
panied by anaemia and debility the tongue is 
Flf} - 8fl - pale, broad, and indented at the edges. The 

breath is generally quite offensive. The sali- 
vary secretion is increased ; the stomach fre- 
quently appears considerably distended, and 
is tender on pressure immediately below the 
ensiform cartilage. The urine is generally 
diminished, and frequently exhibits a sedi- 
ment containing urates, oxalates, or phos- 
phates. The bowels are usually constipated, 
unless intestinal catarrh be associated with 

Sarcinu vcrttriculi, with ., , . ,. , -\r , • • p ^ 

starch granules and oil glob- the S? 8 *™ disorder Vertigo is frequently 
ules, from vomited matters, experienced, especially on arising in the 
(Otto Funke.) morning. Palpitation of the heart and other 

cardiac neuroses sometimes occur. The pa- 
tient complains of great depression and gloom, which may increase to 
the proportions of actual melancholia. Agoraphobia and allied mental 
disturbances are sometimes experienced. In chronic cases the general 
health suffers, and a certain degree of emaciation may be observed. 
Eczema, urticaria, and hemorrhagic symptoms sometimes exist. 

The duration of the disease is exceedingly chronic. Improvement 
or apparent recovery is liable to be followed by relapses, and the dis- 
ease frequently continues until the end of life. Complete atrophy of 
the gastric glands produces progressive exhaustion, and death follows 
with the symptoms of progressive pernicious anaemia. In other cases 
dilatation of the stomach or malignant disease may result from chronic 
catarrhal inflammation. 

Diagnosis. In order to investigate accurately the condition and 
functional capacity of the stomach, it becomes necessary to withdraw 
a portion of its contents, and to subject them to chemical analysis. In 
this way the presence or absence of free hydrochloric acid and of pepsin 
and other ferments may be ascertained. In order to procure a speci- 
men of the gastric contents, the patient should be instructed to take a 
meal consisting of a cup of tea, without sugar, and a biscuit. At the 
expiration of an hour the stomach may be evacuated by the aid of a 
gastric syphon-catheter, or an ordinary flexible rubber tube, which is 
introduced through the oesophagus into the stomach and connected with 
an aspirator. In this way two or three ounces of fluid may be with- 
drawn and, after filtration, subjected to analysis. If a more extended 
investigation be desired, the patient should be instructed to take a bowl 
of soup and a tender beefsteak, with an egg and a piece of bread. 
After the expiration of four hours the contents of the stomach may be 
withdrawn. If at the expiration of six hours the stomach contains a 
considerable quantity of liquid, its muscular power is evidently dimin- 
ished, for after that length of time the healthy stomach should have 
been completely emptied by the propulsion of its contents into the 
duodenum. 

Having withdrawn and filtered the contents, it becomes necessary to 



DISEASES OF THE STOMACH. 333 

determine the presence or absence of free hydrochloric acid. For this 
purpose a few drops of the filtered liquid may be added to a solution of 
tropseoline (0.05 : 200). If a free acid is present, the point of contact 
between the two liquids is indicated by a violet-red color. Its presence 
is also indicated by the appearance of a blue spot when congo paper is 
moistened with a drop of the gastric juice. 

Having now determined the presence of a free acid, the liquid must 
be tested with phloroglucine-vanilline (phloroglucine, 2.0 ; vanilline, 
1.0 ; alcohol, 30). This reagent must be kept in a colored vial, because 
it is readily decomposed in daylight. A few drops of the reagent must 
be evaporated in a porcelain capsule with an equal quantity of gastric 
juice. The presence of free hydrochloric acid is indicated by a carmine- 
red residuum. 

In order to ascertain the presence of lactic acid, it is necessary to 
employ a reagent composed of one drop of the chloride of iron and 10 
c.cm. of a four per cent, solution of carbolic acid, diluted with 20 c.cm. of 
water. The addition of this reagent to a fluid containing lactic acid 
changes its blue color to a canary-yellow tint. 

In order to ascertain the presence of acetic acid, the gastric juice 
should be agitated with ether, which should be then removed by evap- 
oration ; a portion of the remaining liquid must be mixed with water, 
carefully filtered, and treated with a drop of chloride of iron, when a 
blood-red color will be developed if acetic acid is present. Complete 
evaporation causes a reddish-brown deposit of basic acetate of iron. 
The remaining portion of the ethereal residue may be tested for the 
presence of butyric acid hy the addition of a few drops of water and a 
minute fragment of chloride of calcium. If butyric acid is present, it 
will appear upon the surface of the liquid in the form of minute oil 
globules. 

Having determined the presence of free hydrochloric acid, its pro- 
portionate amount must be ascertained by quantitative analysis. For 
this purpose it may be titrated with a standard decinormal solution of 
caustic soda, and the acid contents may be estimated by the equation 
1 c.cm. of the standard solution = 0.003646 grm. of hydrochloric 
acid. Since it is known that normal gastric juice contains 0.15-0.25 
of that acid, hypacidity of the gastric fluid will be indicated whenever 
it contains less than 0.15 per cent, of hydrochloric acid ; while, on the 
contrary, hyperacidity is indicated by the presence of anything more 
than 0.3 per cent, of acid. 

In order to test the presence of pepsin, equal-sized fragments of 
coagulated egg albumen may be placed in four test-tubes, marked 1, 2, 
3, and 4. In the first may be placed a specimen of the plain gastric 
juice ; in the second the same quantity should be mixed with five or six 
grains of pepsin ; in the third it should be reinforced with one or two 
drops of hydrochloric acid ; and in the fourth with both pepsin and 
hydrochloric acid. The four tubes should then be placed in a warm 
chamber, at the temperature of the body. If the albumin in No. 2 is 
very slightly, or not at all dissolved, there is lack of hydrochloric acid. 
If the process of solution is very gradual in Xo. 3, a lack of pepsin is 
indicated ; while in No. 4 normal solution should take place, since pepsin 



334 DISEASES OF THE ALIMENTARY CANAL. 

and hydrochloric acid are here artificially combined. If similar solution 
takes place in No. 1, pepsin and hydrochloric acid are naturally present 
in normal quantity. 

The presence of milk ferment in the gastric juice may be ascertained 
by the addition of an equal quantity of neutral milk to properly neu- 
tralized gastric juice, when the presence of ferment will be indicated, 
in the course of a few minutes, by the coagulation of casein. 

In order to ascertain the rate of absorption from the stomach, the 
patient may be made to swallow a few grains of iodide of potassium 
in a gelatin capsule. The saliva should then be tested every five 
minutes for the presence of iodine. This may be rapidly accomplished 
by the aid of starch-paper and nitric acid. The presence of iodide of 
potassium will be indicated by a red or blue color when the paper is 
moistened with saliva and a drop of fuming nitric acid. In healthy 
persons the reaction should be apparent in the course of fifteen minutes, 
if the stomach be empty. Severe gastric disease occasions great delay 
in the reaction. 

Having ascertained the condition of the gastric juice, it becomes 
necessary to ascertain whether other diseases of the stomach, especially 
cancer or ulcer, are present. The existence of a tumor in the epigastric 
region may be the consequence of other diseases by which the gastric 
wall has been thickened. The development of cachexia and advanced 
age favor the probability of cancer. The absence of hsematemesis- 
argues in favor of simple inflammation. Absence of free hydrochloric 
acid from the gastric juice, and the presence of enlarged lymph glands 
in the left inguinal region, or above the left clavicle, generally indicate 
cancer. 

Hydrochloric acid may be absent in cases of chronic atrophy of the- 
gastric glands ; but blood, which is usually present in cancer, will then 
also be absent from the mucus that is vomited. 

Ulceration of the stomach generally occurs in young, anemic, or 
chlorotic females. The pain is more severe and circumscribed than in 
general catarrhal inflammation, and it is usually increased by taking 
food. Copious hsernateniesis also indicates gastric ulcer. 

Prognosis. The prognosis in chronic gastric catarrh depends upon 
the cause, and upon the possibility of its removal. 

Treatment. The diet must be strictly regulated, and the patient 
must be instructed that food shall be taken leisurely, in moderate 
quantities, and thoroughly masticated. The clothing must, also, be 
sufficiently warm to prevent the possibility of chill. 

In all cases the greatest reliance must be placed upon the quality of 
the food. Soup, beef-tea, peptonoids, milk, and soft eggs are the articles 
most easily digested. Calves' brains, sweetbreads, pig's feet, and poultry 
stand next in order ; then follow tenderloin steaks, well pounded and 
broiled. Still more substantial, but less easily digested, are roasted, 
poultry and game, rare roast beef, veal, fish, macaroni, and soup. New 
bread, fats, starches, and vegetables must be forbidden ; stale bread 
toasted may be allowed. It will be necessary to prescribe the amount 
of food, and the exact time for each meal; the menu should be fre- 
quently varied in order to prevent loss of appetite. 



DISEASES OF THE STOMACH. 335 

It occasionally happens that patients revolt against such regulation 
of their diet, and claim to feel better when they are allowed the use of 
mustard and spices, with dried and smoked meats. 

Chlorotic and anaemic patients are frequently benefited by the admin- 
istration of dilute hydrochloric acid in ten-drop doses in a wineglass of 
warm water about an hour after eating. If pepsin be deficient in the 
gastric juice, ten grains of the powder may be taken at the same time. 

Fermentation in the stomach must be arrested by the use of salicylic 
acid (10 grains half an hour before each meal), or creasote (1 or 2 drops 
in pill form before each meal). When food stagnates for a long time in 
the stomach, and when there is excessive fermentation, it is well to 
empty the stomach every morning with a syphon, by the aid of which 
the stomach should be thoroughly washed with tepid water, and irrigated 
with a solution of salicylate of sodium, or of resorcin, or with a two 
per cent, solution of bicarbonate of sodium if there be great acidity. 

When the peristaltic vigor of the stomach is reduced, bitters should 
be prescribed, e. g., tincture of mix vomica (10 drops three times a day), 
elixir of calisaya bark (a tablespoonful three times a day), and infusion 
of condurango (a tablespoonful three times a day). 

Severe gastric pain must be relieved by the administration of mor- 
phine (morph. sulph. J- gr., acid, hydrocyanic, dilut. 3 gtt.). Extract 
of belladonna and hydrate of chloral are sometimes beneficial. Bis- 
muth, nitrate of silver, and opium should be avoided if possible. 
Pyrosis and heartburn may be relieved by the use of calcined magnesia. 
Constipation requires the use of compound licorice powder (one or two 
teaspoonfuls in water at bedtime) or compound rhubarb pills. 

The general health of the patient must be improved by change of 
air and occupation, cold bathing, massage, and exercise in the open 
air. Faradic electricity is very beneficial, when employed by the 
application of one pole upon the back of the neck, while the other is 
moved from place to place over the region of the stomach. The waters 
of various mineral springs have a well- deserved reputation in the 
treatment of chronic catarrhal gastritis. The alkaline springs should be 
advised in cases which are attended with excess of acid in the stomach. 
The alkaline chloride waters are more useful in cases that are accom- 
panied by nausea and excessive secretion of mucus ; and strong saline 
waters are indicated when constipation and hepatic obstruction exist. 
Anaemic patients are benefited by waters that contain iron. 

Purulent Gastritis — Gastritis Phlegmonosa. 

Purulent gastritis occurs during middle age more frequently among 
men than among women, and is usually excited by corrosive or caustic 
poisons, though it is sometimes developed in connection with infective 
diseases or as a consequence of injuries, errors of diet, and exposure to 
cold. 

The inflammation may be either diffuse or circumscribed. It in- 
volves the submucous tissue, which becomes infiltrated with pus and 
the ordinary products of inflammation. This may involve the entire 
thickness of the gastric wall, and it may find its way into the cavity of 



336 DISEASES OF THE ALIMENTARY CANAL. 

the stomach or of the peritoneum. The symptoms do not differ essen- 
tially from those which are presented by ordinary severe inflammation 
of the stomach. Only when pus appears in the vomit can the disease 
be certainly recognized. Sometimes a circumscribed abscess can be 
recognized as a distinct tumor beneath the abdominal wall. The 
course of the disease is usually brief. A fatal result is generally 
reached before the end of the second week. The treatment must 
necessarily be purely symptomatic. 

Toxic Inflammation of the Stomach — Gastritis Toxica. 

The term toxic inflammation is applied to all forms of gastritis that 
are produced by the ingestion of poisons. Of these the mineral acids, 
oxalic acid, caustic alkalies, arsenic, and corrosive sublimate are the 
most common. The mouth, fauces, oesophagus, and gastric mucous 
membrane are discolored and corroded in a manner that corresponds 
with the action of each article upon the external skin. Sulphuric 
acid blackens the membranes, nitric acid produces a yellow stain, and 
ammonia causes a gray or brown discoloration of the surface. In 
doubtful cases litmus-paper may be used to ascertain whether an 
acid or an alkali has been swallowed. 

The amount of destruction which occurs in the tissues of the stomach 
is dependent upon the quantity of the poison that has reached its 
cavity. Death may result speedily from shock or from complete corro- 
sion and perforation of the gastric wall : but recovery sometimes takes 
place, and is followed by cicatricial contractions that may lead to a 
fatal result at a later period. The inflammatory process is accompanied 
by severe burning pain that is referred to the epigastrium and along 
the spinal column. Hiccough and vomiting and unquenchable thirst 
torment the patient. Blood and d6bris exist in the matters that are 
vomited or are voided by stool. Peritonitis or perforation are in- 
dicated by the extension of pain, with increased prostration and other 
symptoms of peritonitis or collapse. 

The indications for treatment are the neutralization of the poison 
with alkalies, if an acid have been swallowed ; or with vinegar, if it 
were an alkali. The whites of eggs should be administered freely in 
cases of corrosive sublimate poisoning, and the stomach must be 
evacuated as speedily as possible. Subsequent gastritis should be 
treated on general principles, like any other form of acute inflammation 
of the stomach. 

Gastric Ulcer — Ulcus Ventriculi Rotundum. 

Pathological Anatomy. It is estimated that gastric ulcer exists 
in about five per cent, of the subjects which are examined after death. 
It occurs, in nearly half the cases, upon the posterior wall of the stom- 
ach ; in about as large a proportion upon the lesser curvature and 
P3doric extremity of the organ. It it a rare event to find more than 
one ulcer. Its size may vary from half an inch to three or four inches 
in diameter. Its form is round or oval, with a sharply defined border 



DISEASES OF THE STOMACH. 337 

as if it had been punched out of the mucous membrane. Sometimes the 
submucous and muscular layers are also invaded, producing a funnel- 
shaped cavity with its point toward the peritoneal layer, which, at last, 
may be itself penetrated. The consequences of such perforation are, 
however, often averted by adhesive inflammation between the surround- 
ing peritoneal surface and adjacent structures. In this way, by adhe- 
sion with the neighboring peritoneal surface, a circumscribed abscess 
may be formed which communicates with the cavity of the stomach. 
In other cases, when the gastric peritoneum effects an adhesion with a 
neighboring organ like the liver or the spleen, the substance of that 
organ forms the base of the ulcer, and may be invaded still further by 
the inflammatory process. Large abscesses may be thus originated, 
and may finally penetrate the diaphragm, opening a communication 
between the stomach and any one of the thoracic cavities or intra-tho- 
racic organs. The ulcerative process may involve the anterior wall of 
the abdomen, thus originating a gastric fistula. The invasion of the 
peritoneal cavity results in peritonitis, which is usually fatal. In con- 
nection with these extensive processes arises great danger of arterial 
erosion and fatal hemorrhage. 

If ulceration does not result in perforation, recovery is not always 
devoid of evil consequences. Cicatricial contraction sometimes causes 
great reduction in the dimensions of the stomach ; the organ is some- 
times constricted so as to resemble an hour-glass, or it may assume an 
irregularly sacculated form, suggestive of the stomachs of a ruminating 
animal. 

Etiology. The disease is most frequently observed among chlorotic 
young women during the first fifteen years of adult life. It sometimes 
occurs in connection with chronic infective diseases, or as a consequence 
of arteriosclerosis, or of pigmentary embolism in the vessels of the 
stomach. 

Intemperate habits and coarse vegetable food favor the development 
of the disease. It may also occur as a consequence of inflammation or 
injury of the stomach ; and it is not unfrequently observed after exten- 
sive burns or scalds involving the external surface of the body. 

The circular form of a gastric ulcer seems to indicate its dependence 
upon local disease involving the bloodvessels and their branches. The 
frequent occurrence of ulceration in syphilis, in consumption, and in 
chlorosis, which produce amyloid or fatty degeneration of the arterial 
walls, favors the opinion that ulceration is dependent upon vascular 
disease. But it is probable that something more than vascular disease 
is requisite to determine the occurrence of ulceration, otherwise that 
process might be multiple, or nearly universal, instead of being restricted 
to a single point, as is usually the case. In like manner the depend- 
ence of the disease upon a reduction of the alkalinity of the blood is 
hardly probable, since a wider extension of ulcerative processes might 
then be expected. It is probable that local causes, such as vascular 
obstructions, injuries, and parasitic invasions, in concurrence with an 
altered condition of the blood, combine to favor the erosive action of 
the gastric juice at the point of least resistance which has thus been 
created. 

22 



33 S DISEASES OE THE A LI ME XT ART CANAL. 

SYMPTOMS. It is probable that small ulcers may exist without nota- 
ble symptoms ; at any rate, the occurrence of profuse gastric hemor- 
rhage or perforation in a person who had previously enjoyed apparent 
health, can hardly be explained without the hypothesis of a preexistent 
ulcer. Ordinarily, there is great complaint of pain in the region of the 
stomach, either immediately after eating, or one or two hours after the 
meal-time. Painful sensations are referred to the sub-sternal or ensi- 
form region, or to the intra-scapular space. When ulceration affects 
the posterior wall of the stomach, pain is frequently increased by lying 
in the dorsal position. An increase of pain when other positions are 
assumed argues in favor of a corresponding location of the ulcer. 

Vomiting is a very common symptom. It occurs especially in the 
morning, or when the stomach is empty. It sometimes follows the 
ingestion of particular kinds of food. Sometimes streaks of blood 
appear in the mucus that is evacuated. One of the most significant 
symptoms is the occurrence of hazmatc metis : it may be excited by 
unusual exertion, distention of the stomach, or as a consequence of 
menstrual suppression. The quantity of blood varies within very wide 
limits. It ordinarily appears in the form of dark clots which possess 
a very acid reaction. If very copious in amount, the blood may present 
an arterial character. It occasions vomiting, and. if hemorrhage be 
excessive, the symptoms of collapse are developed. The loss of a small 
quantity of blood does not produce such acute symptoms, but its pres- 
ence is indicated by a coffee-ground sediment in the vomited matter. 
Sometimes the patient complains of a sensation of heat, or of trickling 
in the stomach, which is followed by vomiting. Occasionally, blood 
may find its way into the air-passages during the act of vomiting. 
The stomach is frequently distended and painful on pressure, especially 
if the seat of the ulcer be upon the anterior surface of the organ. 

The gastric juice always contains an excessoffree hydrochloric acid. 
The bowels are constipated, and altered blood is sometimes visible in 
the stools. The urine is scanty and diminished in quantity. The 
appetite and thirst often remain without notable change: and the gen- 
eral condition of the patient is often such as to excite surprise at the 
occurrence of gastric disease. As in other disorders of the digestive 
apparatus, there may be great depression of spirits, accompanied by 
sleeplessness. 

Among the most formidable complications of gastric ulcer may be 
mentioned peritonitis, in consequence of perforation of the stomach. 
If the abdominal wall is penetrated by ulceration, subcutaneous em- 
physema has been observed. The various consequences of perforation 
and consequent communication with the thoracic cavities have already 
been mentioned. Thrombosis of the portal v>.in may arise as a com- 
plication. 

As sequelae of gastric ulcer are sometimes observed cicatrization and 

f the pylorus, with subsequent dilatation of the stomach. 

Occasionally the pyloric orifice becomes incontinent by reason of 

ulceration and destruction of its muscular sphincter. One of the most 

formidable consequences of gastric ulcer consists in the development of 

u & ise at a later period of life. 



DISEASES OF THE STOMACH. 339 

Diagnosis. The diagnosis of a gastric ulcer is usually easy when 
a chlorotic young female exhibits hyperacidity of the gastric juice asso- 
ciated with pain, vomiting and haematemesis. But it is not always 
easy to differentiate the disease from other chronic gastric disorders, 
viz., chronic catarrhal inflammation, gastric neuralgia, cancer, and 
biliary colic, which are characterized as follows : 1. Chronic gastritis 
may be recognized by its dependence upon errors of diet ; by the lesser 
degree and greater diffusion of pain ; absence of haematemesis, and the 
comparatively speedy recovery. 2. Gastric neuralgia is not dependent 
upon taking food into the stomach, and is relieved by pressure upon 
the epigastrium. Hsematemesis is absent, and there are usually other 
forms of associated neuralgia. 3. Cancer of the stomach occurs at an 
advanced period of life ; is usually attended by cancerous cachexia ; 
runs a rapid course, and occasions enlargement of the lymph glands 
above the left clavicle and in the groin. A tumor is sometimes present 
in the epigastrium, and free hydrochloric acid is absent from the gastric 
juice. 4. Gall-stone colic is accompanied by pain which is restricted 
to the region of the gall bladder. Vomiting and jaundice are com- 
monly associated with the colic. Careful scrutiny of the stools may 
possibly result in the discovery of gall stones. 

Prognosis. The prognosis in gastric ulcer must be very guarded, 
since so many dangerous complications and sequelae may attend its 
course. 

Treatment. The patient should remain in bed, with a warm poul- 
tice over the stomach, and should be restricted to a milk diet. This 
may be given in the form of koumiss, or boiled in a thin porridge. It 
should be taken in small quantities and very frequently, so as to avoid 
distention of the stomach with curdled masses. Excessive acidity may 
be obviated by the use of lime-water or by the bicarbonate of sodium. 
If a milk diet cannot be tolerated, it may be mixed with an equal 
quantity of beef- tea, or, as substitutes, broths, skimmed free from 
grease, beef peptonoids, bouillon, and soft eggs may be given. Rectal 
feeding also becomes necessary. 

Internal medication may be undertaken by the administration of 
subnitrate of bismuth, or the salicylate, in ten-grain doses three times 
a day. Nitrate of silver (one-sixth of a grain in pill form three times 
a day) and acetate of lead (in grain doses every two or three hours) 
are recommended. In cases associated with hepatic engorgement, 
Carlsbad waters, or the artificial Carlsbad salts, may be administered 
every morning, half an hour before breakfast. Severe pain must be 
relieved by hypodermic injection of morphine and atropine, or by the 
internal administration of morphine and hydrocyanic acid. 

Be. — Morph. sulph gr iv. 

Acid, hydrocyanic, dilut TT11. 

Aquae destill <§ij. — M. 

S. — One drachm three times a day. 

Chloral hydrate, in ten-grain doses three times a day, is sometimes 
useful for the same purpose. Obstinate vomiting may be relieved by 
swallowing small pieces of ice, or by morphine in minute doses (one- 



340 DISEASES OF THE ALIMENTARY CANAL. 

thirtieth of a grain every half-hour), or by the compound tincture of 
iodine (one drop in a wineglassful of water every two hours). 

Perforation and peritonitis must be treated by warm poultices 
externally, and large doses of opium (one grain every two hours) 
internally. 

Cancer of the Stomach. 

Etiology. Cancer of the stomach is a less frequent occurrence 
than gastric ulcer. It is observed in about two per cent, of the 
patients who are examined after death. It is a disease of advanced 
life, and is especially frequent among the poor whose diet is coarse and 
innutritious. Heredity is not without influence in its production, and 
males suffer somewhat more frequently than females. Certain countries 
and climates appear to be more than ordinarily favorable to the inci- 
dence of the disease. Depressing influences of a psychical character, 
intemperance in the use of strong alcoholic liquors, and chronic dis- 
eases of the stomach all operate to favor the development of cancer. 

Pathological Anatomy. Cancer of the stomach is, in the vast 
majority of cases, a primary disease. Its favorite seat is in the pyloric 
region ; after that, the cardia and lesser curvature of the organ are 
most frequently invaded. Sometimes the disease appears as a circum- 
scribed tumor; in other cases there is diffuse infiltration of the gastric 
wall. Cancerous tumors are irregular in form, and exhibit a tendency 
to local degeneration and breaking down of substance. Infiltration is 
attended with great thickening of the coats of the stomach, so that its 
cavity is often considerably reduced in size. The mucous membrane 
becomes ulcerated, but gangrenous processes are rarely observed, by 
reason of the antiseptic properties of the gastric juice. The uninvaded 
portions of the mucous membrane are generally the seat of chronic 
catarrhal inflammation. 

Cancer of the stomach most frequently exhibits the scirrhous variety : 
soft cancers of the medullary variety stand next in order; while 
colloid cancer is very likely to involve the peritoneum. 

Invasion of the pylorus frequently occasions obstruction and dilata- 
tion of the stomach. The weight of the tumor sometimes displaces the 
pyloric extremity, so that it may lie in the iliac or hypogastric region. 

Profuse hemorrhage may occur as a consequence of degeneration or 
erosion of a laro-e bloodvessel. In other cases the hemorrhage is re- 
stricted to a capillary oozing from the affected surfaces. As a conse- 
quence of the propagation of the disease along the lymph vessels and 
veins, distant organs may become involved by the formation of second- 
ary tumors. Circumscribed peritonitis may also occur. The lymph 
glands within the abdominal and thoracic cavities generally share in 
the process of cancerous infiltration. Brown atrophy of the heart, 
fatty or amyloid degeneration of the heart and kidneys, and other 
evidences of chronic marasmus, are frequently observed. 

Symptoms. Cancer of the stomach not unfrequently develops in- 
sidiously, without local symptoms, the only evidence of its existence 
being furnished by indigestion and progressive cachexia. The pres- 
ence of a tumor in the gastric region forms one of the most important 



DISEASES OF THE STOMACH. 341 

local signs. Frequently the growth is concealed behind the stomach, 
in its posterior wall, so that it only becomes apparent after it has 
attained considerable magnitude. When it can be felt, it presents the 
form of a round, or oval, or somewhat irregular mass, which is not dis- 
placed by the movements of respiration unless adhesions have been 
contracted with the liver or with the diaphragm. The position of the 
body frequently influences the location of the tumor, so that it can some- 
times be detected more easily when the patient lies upon one side or 
assumes the knee-elbow posture. Distention of the stomach with food 
or with gas sometimes aids in rendering the tumor more prominent. 
If it lies upon the abdominal aorta, pulsations may be perceptible, but 
they differ from the uniformly expansive pulsations of aneurism. Per- 
cussion over the tumor indicates tympanitic dulness. Auscultation 
gives no decisive indications. 

In the absence of a tumor the general symptoms and the occurrence 
of gastric hemorrhage afford the most valuable indications of disease. 
Hemorrhage is usually very moderate and the vomited matters rarely 
contain clotted blood On the contrary, the presence of blood is indi- 
cated by the characteristic coffee-ground sediment, which consists of 
broken-clown blood corpuscles and dark-brown pigment. The stools 
should be carefully examined for indications of blood. Sometimes 
cancerous elements may be discovered by the aid of the microscope. 

Mucus and bile are frequently vomited by cancerous patients, and 
when such an event frequently recurs in the case of an elderly person, 
and is associated with progressive emaciation, cachexia, and infiltration 
of the lymph glands in the neck and groin, the probability of gastric 
cancer reaches a very high degree. 

The function of digestion is very seriously disordered in cancer of 
the stomach. Eructation of acid and, sometimes, offensive gases is a 
very common incident. Free hydrochloric acid and the gastric fer- 
ments are usually absent from the gastric juice. The process of 
absorption is greatly retarded, as may be shown by testing the saliva 
after the administration of iodide of potassium ; and the peristaltic 
movements of the organ are also greatly impeded, so that food may 
remain for an unusual length of time in its cavity. 

Pain, of a boring or burning quality, is often experienced, especially 
after taking food. Associated neuralgic pains, and paroxysms of 
asthma, or angina pectoris, sometimes occur. There is tenderness on 
pressure over the stomach. The tongue is frequently coated or exces- 
sively red and fissured, especially when acid vomiting often occurs. 
The bowels are almost always constipated, though, in the later stages 
of the disease, diarrhoea sometimes exists as a consequence of the 
extension of catarrhal inflammation to the intestinal surfaces. The 
urine is scanty, and sometimes contains large quantities of indican, 
which may be recognized by adding two or three drops of a concen- 
trated solution of chloride of calcium to a test-tube containing equal 
parts of urine and pure hydrochloric acid. Loss of appetite, progres- 
sive emaciation, universal distress, insomnia, and general prostration 
gradually wear out the patient. Sometimes fever is developed as a 



342 DISEASES OF THE ALIMENTARY CANAL. 

consequence of septic poisoning during the absorption of broken-down 
cancerous masses. 

The duration of the disease is difficult to ascertain, in consequence 
of the insidious character of its invasion. Death occurs, sometimes, in 
the course of a few weeks. Life has been prolonged in certain cases 
for two or three years : generally the younger the patient the more 
rapid the course of the disease. 

Among the complications of gastric cancer are dilatation of the 
stomach, by reason of pyloric constriction: pyloric insufficiency, as a 
consequence of destruction of its sphincter muscle : aesophag 
strict-ion, as a consequence of cancer involving the cardiac orifice of the 
organ: sometimes secondary invasion of the liver or other organs pro- 
duces symptoms which quite overshadow the primary gastric disease. 
In like manner, copious hemorrhage, or peritonitis, or the invasion of 
the other digestive organs and cavities, may produce an overwhelming 
array of symptoms leading directly to death. 

Diagnosis. The recognition of cancer of the stomach is not always 
easy during life. Xot unfrequently old people gradually waste away 
and die without any objective symptoms which particularly attract the 
attention, but after death an unsuspected cancer may be found in the 
stomach. All doubtful cases should be carefully examined with refer- 
ence to the condition of the gastric juice, though free hydrochloric acid 
is frequently absent in conditions of amyloid degeneration of the kid- 
neys, liver, or spleen. Those diseases are so rare that cancer should be 
suspected whenever hydrochloric acid cannot be detected in the gastric 
juice. The retardation of gastric absorption which is shown by the 
iodide of potassium test, affords one of the best evidences of gastric- 
cancer, though it does sometimes occur when chronic gastric catarrh or 
dilatation exist. It must not. however, be concluded from the presence 
of free hydrochloric acid that a latent cancer of the stomach may not 
exist, for sometimes indigestion, cachexia, and enlargement of the 
supra-clavicular glands form the only evidences of the disease. It is also 
desirable to estimate the amount of haemoglobin in the blood, since 
gastric cancer is rarely present when the amount of haemoglobin is 
greater than sixty per cent, of the normal quantity. 

When an abdominal tumor can be recognized during life it must be 
differentiated from enlargement and neoplasms of the liver or spleen by 
its lack of mobility during the movements of respiration. It must also be 
carefully differentiated from fecal and intestinal tumors, from enlargement 
of the lymph glands, from tumors involving the pancreas, the mesentery, 
the uterus, and the ovaries, and from aneurismal dilatation nnd cir- 
cumscribed peritoneal effusions. Great assistance can be obtained by 
filling the stomach with gas. either by inflating it with the aid of the 
bulb of a spray apparatus, or by making the patient swallow a teaspoon- 
ful of bicarbonate nf sodium dissolved in a wineglass of water, followed 
by a similar solution of a teaspoonful of tartaric acid. By the result- 
ing liberation of gas the stomach will be inflated, and the tumor will be 
correspondingly displaced. 

Having demonstrated that the tumor is of gastric origin, it must be 
differentiated from cicatricial indurations produced by previous ulcera- 



DISEASES OF THE STOMACH. 343 

tions, and from foreign bodies which have been intruded into the 
stomach. The diagnosis of cancer will then be established by the con- 
currence of advanced age, retarded absorption, persistent absence of 
free hydrochloric acid, and progressive cachexia. 

Treatment. There is no remedy yet discovered for the cure of 
cancer. Surgical operations afford temporary relief in a few cases, but 
are generally either immediately fatal or speedily followed by a relapse 
of the disease and death. The principal recourse for the relief of the 
patient lies in the administration of narcotics for the relief of pain, 
irrigation of the stomach if its cavity be dilated, restriction of the diet 
to skimmed milk, soft eggs, beef-tea, and peptonoids. The infusion of 
condurango, in tablespoonful doses two or three times a day, has been 
recommended. Pepsin and hydrochloric acid rarely accomplish much 
benefit. 

Polypous tumors sometimes occur in connection with chronic catarrhal 
gastritis, and may, by their size and number, occasionally obstruct the 
pyloric orifice of the stomach. Sarcoma, papilloma, myoma, adenoma, 
lipoma, lymphangioma, teleangiectasis, and cystic tumors have been 
described in connection with diseases of the stomach. 

Dilatation of the Stomach — G-astrectasis. 

Etiology. Any cause that interferes with the propulsion of the 
contents of the stomach will produce dilatation of the organ. This 
may be transitory, when it depends upon accidental and transient 
causes, like excess of eating, or it may be permanent when chronic dis- 
eases interfere with the expulsion of food through the pylorus. Hence, 
the most common cause of dilatation lies in constriction of the 'pylorus 
or of the duodenum. This condition is usually produced by cicatriza- 
tion of an ulcer that encroached upon the pyloric portion of the stomach. 
Cancerous disease of the pylorus, muscular hypertrophy dependent upon 
chronic gastritis, and polypous tumors which develop in the neighbor- 
hood of the pylorus are among the most common causes of stenosis. 
Similar incidents involving the upper portion of the duodenum may 
effect like results. Sometimes tumors which originate outside of the 
stomach may compress the pyloric orifice of the duodenum, and thus 
produce stenosis. Wandering kidney, when the right kidney is dis- 
placed, may produce a similar effect, though in what way it is accom- 
plished is not yet decided. Congenital constrictions of the pylorus 
may sometimes operate as a cause of dilatation. 

Dilatation of the stomach is not unfrequently occasioned by deficient 
vigor in its muscular layer. This lack of tone may be dependent 
upon chronic catarrhal inflammation, or it may exist as a consequence 
of defective nutrition subsequent to wounds, injuries, or chronic diseases 
which are attended with deficient absorption and assimilation. 

Gastric dilatation is a not uncommon event among those who eat and 
drink inordinately ; hence, it is more frequently observed among people 
who live upon a vegetable diet. It may be observed as a consequence 
of the excessive consumption of liquids by diabetic patients, and in one 



3M DISEASES OF THE ALIMENTARY CANAL. 

case, at least, it has been known to occur by reason of the intemperate 
use of milk by a patient who had learned to relieve gastralgia with a 
mouthful of milk whenever pain recurred. He consequently found it 
necessary to carry a bottle in his pocket, from which he took a draught 
every few minutes, gaining in the course of some months over eighty 
pounds in weight, and acquiring a stomach that would contain at least 
a water-pailful. 

Pathological Anatomy. The stomach becomes, in certain cases, 
immensely enlarged, and occasions a corresponding displacement of 
other organs. The diaphragm is crowded upward, and the heart is dis- 
placed to the left. The cardiac portion of the stomach exhibits the 
greatest evidence of dilatation, in which the oesophagus sometimes takes 
part when the pylorus or duodenum are constricted. The mucous 
membrane of the stomach is in a state of chronic catarrh. The mus- 
cular layer is greatly hypertrophied when nutrition is not reduced, but 
it is atrophied when exhausting diseases interfere with nutrition. 

Symptoms and Diagnosis. The symptoms of dilatation of the 
stomach depend upon the chemical changes which take place in the 
gastric juice, and upon the physical alterations which the organ itself 
has experienced. In the early stages of the disease the errors of diges- 
tion that it produces are similar to those which occur in connection with 
chronic gastric catarrh, but, as the disease advances, nutrition fails ; 
emaciation, pallor, and debility make startling progress. The appetite 
sometimes fails, or is replaced by excessive hunger, especially when the 
contents of the stomach are voided by vomiting rather than by passage 
into the duodenum. Hiccough and heartburn are not uncommon. 
The gases which are eructated are generally odorless, though sometimes 
offensive, and occasionally they contain inflammable marsh gas, which 
may be actually ignited as it escapes from the moath. Vomiting is 
one of the most common occurrences during the early stages of the dis- 
ease ; but, as the stomach enlarges, it occurs less frequently. The 
gastric contents are thrown up with very little apparent effort, and they 
exhibit a degree of acidity that is sometimes sufficient to corrode the 
teeth. Frequently the evacuated liquids ferment and froth like yeast 
after they have been vomited. They contain lactic, butyric, and acetic 
acids, together with undigested food. Microscopical examination fre- 
quently discovers yeast cells and sarcinse ventriculi, together with 
numerous other parasitic organisms. 

In severe cases of dilatation the gastric region is inordinately promi- 
nent, and extends below the navel. In emaciated patients the contour 
of the organ can frequently be discerned through the wall of the abdo- 
men, and its peristaltic movements may be readily perceived. This 
movement is occasionally excessive, and productive of great uneasiness 
and distress in the abdominal region. 

Palpation encounters a feeling of resistance, like that of a bladder 
filled with water, and in this way the dimensions of the organ can be 
quite accurately marked out. When gas and liquids occupy the stom- 
ach at the same time, a loud succussion sound can often be heard when 
the bod} 7 is violently shaken. This symptom, however, must not be 
referred to dilatation of the stomach unless other evidences of that con- 



DISEASES OF THE STOMACH. 345 

dition exist, for it frequently is present in healthy stomachs when water 
and air jointly occupy its cavity. Sometimes a sense of fluctuation 
may be distinguished on pressure over the stomach. Sometimes, when 
a long oesophageal sound has been introduced into the stomach, its 
point can be felt by pressure through the abdominal wall over the 
greater curvature of the organ. 

Percussion occasions a deep, tympanitic, and frequently metallic note 
over the dilated stomach. Dulness may be recognized over those portions 
which are occupied by liquid, and its location varies in accordance with 
the position of the patient. In cases of obscurity the stomach may be 
inflated by the aid of the bulb of a spray apparatus in connection with 
the oesophageal catheter, or by the liberation of carbonic acid within 
the gastric cavity (p. 342), and the outlines of the dilated organ can be 
then readily defined by percussion. If, under such circumstances, the 
stomach does not become inflated, but the intestines receive the gas, it 
is evidence of pyloric incontinence, a condition that is not inconsistent 
with gastric dilatation. 

Auscultation of the stomach, while its cavity is occupied by freshly 
liberated carbonic acid gas, renders audible the crepitant air-bubbles 
which form and break upon the surface of the liquid. In this way the 
limits of the organ may be defined by audible sounds. 

Sometimes the diagnosis can be assisted by distending the colon with 
water from a fountain- syringe. In this way the line of demarkation 
between the stomach and the intestine may be more readily per- 
ceived. 

Gastric digestion is very greatly retarded in cases of dilatation of 
the organ. The gastric syphon frequently brings to view fragments of 
food which were swallowed several days previously. The process of 
absorption is also greatly impeded, so that the recognition of iodide of 
potassium in the saliva may be delayed for one or two hours, instead of 
appearing at the expiration of ten or fifteen minutes, as it should do in 
health. 

As a consequence of fermentation in the gastric contents, acetic acid, 
lactic acid, butyric acid, carbonic acid, and free hydrogen are produced 
by the progressive oxidation of the products which follow the action 
of organized ferments upon sugar. These acid bodies are present in 
great abundance, while free hydrochloric acid is absent when gastric 
dilatation is dependent upon cancerous disease. 

The bowels are usually much constipated, and the urine exhibits 
an alkaline reaction, with an abundance of triple phosphates in the 
sediment. 

Progressive debility, universal discomfort, cardiac palpitation, and 
subjective dyspnoea are matters of common occurrence. Frequently 
the cardiac apex is displaced into the fourth intercostal space by reason 
of the upward pressure of the stomach. The duration of the disease is 
exceedingly variable, and may be very greatly protracted in cases that 
are not dependent upon malignant disease. 

Treatment. For the local relief of the stomach the organ should 
be evacuated by the aid of a gastric syphon, which consists of a funnel 
and rubber tube, connected by a glass tube with an ordinary soft gastric 



346 DISEASES OF THE ALIMENTARY CANAL. 

catheter. Having introduced the catheter through the oesophagus into 
the stomach, tepid water may be poured through the funnel into the 
tube until it is filled : then, compressing the tube immediately under 
the funnel, and depressing its orifice below the level of the stomach, 
water and the liquid contents of the organ will escape when pressure is 
removed from the pipe. If the entrance of the catheter should become 
obstructed, it may be reopened by pressure over the abdominal wall, or 
by the aid of the abdominal muscles. If this expedient prove unsuc- 
cessful, it may be necessary to raise the funnel and again to pour a little 
water through the tube. In this way, with a little patience and perse- 
verance, difficulties can be overcome which at first arise from the irrita- 
bility of the fauces. The operation of syphoning the stomach is very 
easy, and many persons readily learn to perform it for themselves. The 
use of such an instrument is much easier and safer than an attempt 
to evacuate the stomach with an ordinary stomach-pump. 

The evacuation of a dilated stomach by the above method produces 
great relief from the symptoms which depend upon distention of the 
organ. Sometimes the operation is attended by dizziness, singing in 
the ears, and muscular spasm, that has, occasionally, been followed by 
death ; but similar consequences have been observed after simple vomit- 
ing, so that it is probable that such formidable symptoms result from 
the extension of a purely local irritation to central nervous organs 
which have been already dangerously intoxicated by the absorption of 
morbid products from a diseased stomach. 

Having evacuated the stomach, it is desirable to invigorate the con- 
tractile power of its muscular layers ; consequently, the patient should 
be placed in bed for a number of hours, with an ice-bag over the 
epigastrium. A hypodermic injection of ergotine. or of the nitrate of 
strychnine (one-fortieth of a grain) should be made into the anterior 
wall of the abdomen. The daily application of the faradic current 
should follow the operation, and may be continued from five to ten 
minutes, with one po ] e applied to the back of the neck, while the other 
is moved about over the anterior wall of the abdomen. 

Five grains of resorcin. or ten grains of salicvlic acid, should be 
taken an hour before the principal meal, in order to disinfect the gastric 
cavity. Food should be given, in small quantity, every two hours ; and 
it must be chiefly of animal origin. Liquids, fats, and starches must 
be avoided as much as possible, in order to prevent fermentation and 
distention of the stomach. The general health should be cared for in 
accordance with general principles. 

Softening" of the Stomach — Gastromalacia. It sometimes happens 
that after death the stomach presents evidences of softening, which may 
also be attended by discoloration of the bloodvessels in those portions 
of the organ that contain liquid. In certain cases the gastric wall is 
found to be ruptured, and its contents have found their way into the 
peritoneal cavity. Much discussion has arisen regarding the nature of 
this process. By the majority of authors it is thought to be a post- 
mortem consequence of the action of gastric juice upon the mucous 
membrane and upon the blood that is contained in its vessels ; but. by 



FUNCTIONAL DISEASES OF THE STOMACH. 347 

some, the opinion is still held that it is actually an ante-mortem event. 
At any rate, its occurrence cannot be recognized during life, and it 
possesses only an anatomical importance. 

Rupture of the Stomach sometimes occurs as a consequence of actual 
violence. It may occur in connection with inflammatory processes in 
neighboring organs that encroach upon the gastric wall ; and it has 
sometimes happened after the introduction of foreign bodies into the 
cavity of the organ. Its occurrence is indicated by sudden pain, col- 
lapse, tympanites, and peritonitis. 

Gastric Parasites. Besides the ordinary parasites which may exist 
in the stomach, maggots and other larvae have occasionally been found 
in vomited matters, evidently derived from eggs that have been swallowed 
with the food. Numerous vegetable parasites are sometimes found. 
Besides yeast fungus, O'idium albicans, Penicillium glaucum, Favus, 
Sarcina ventriculi, and many varieties of the schizomycetes have been 
discovered in the gastric contents. 



CHAPTEE VI. 

FUNCTIONAL DISEASES OF THE STOMACH. 

Motor Neuroses. 

Nervous Vomiting — Emesis Nervosa. 

Etiology. Under the head of nervous vomiting must be included 
all those cases of emesis that are not dependent upon local excitement 
in the stomach, or which are occasioned either by direct disturbance or 
disease of the vomiting-centre in the medulla oblongata, or as a conse- 
quence of its mediate irritation through impressions that are conveyed 
to it from distant organs of the body. The vast majority of cases, there- 
fore, are the result of reflex influences. 

Direct disturbance by which vomiting is produced may be observed 
in cases of hemorrhage, softening of the brain, tumors, shock, and 
wounds that affect the medulla oblongata. 

Psychical causes which operate through the brain may excite vomit- 
ing through their influence upon the medulla. It is also observed in 
the majority of acute diseases of the brain, and during the development 
of cerebral tumors. Variations in the cerebral circulation, and unusual 
movements, such as swinging, seesawing, carriage riding, and sailing, 
frequently excite vomiting. 

Myelitis, multiple sclerosis of the brain and spinal cord, and other 
spinal diseases, are sometimes accompanied by vomiting ; but it is most 



34S DISEASES OF THE ALIMENTARY CANAL. 

frequently observed in tabes dorsalis under the form of gastric crises 
which sometimes occur with great regularity and frequency. 

Irrit tion f the peripheral nerves in any part of the body is fre- 
quently followed by vomiting, in persons of a delicate and sensitive 
nervous organism. In this way. any excitement of the fauces, pharynx, 
nasal membranes, and auricular passages, may excite a paroxysm. In 
like manner, severe respiratory and cardiac diseases are not unfre- 
quently associated with vomiting. Irritation of the pneumogastric 
nerve by tumors and enlarged glands in the neck may produce a similar 
result. 

Any form of abdominal excitement, such as occurs at the onset of 
acute inflammation, embolic processes, calcular obstructions, hernia, 
intussusception, or other obstruction of the intestinal canal, is frequently 
attended by vomiting. 

Diseases and excitement or injury of the sexual organs, both among 
males and females, are not uncommon causes of gastric disturbance and 
vomiting. The vomiting of pregnancy, and that which is occasionally 
observed at the time of menstruation, are familiar examples of this 
variety of nervous disturbance. 

As a consequence of impregnation of the blood with certain pox 
of internal origin, as may be observed in uraemia, in cholaemia. and in 
the course of many infective diseases, vomiting is produced by the 
direct action of contaminated blood upon the centres in the medulla 
oblongata. In a similar way may be explained the action of various 
drugs which excite vomiting when introduced hypodermically, or by 
inhalation, e. g.. apomorphine and ether. 

Symptoms. Notwithstanding frequent recurrence of nervous vomit- 
ing, many patients experience no sensible diminution of health or of 
vigor : but sometimes, as may be observed in the vomiting of preg- 
nancy, great emaciation and exhaustion are produced through the con- 
tinuous evacuation of the stomach, and the impossibility of retaining 
nourishment. The tongue remains clean ; appetite is often vigorous : 
pressure produces no evidence of tenderness over the stomach ; the 
urine is generally diminished in quantity and rich in urates : sometimes 
it is suppressed in hysterical subjects, and the vomited matters may 
contain urinary constituents. 

Diagnosis and Prognosis. A purely nervous cause should never 
be assumed for persistent vomiting, unless other diseases can be ex- 
cluded. When the tongue remains clean, and there are no evidences 
of gastric disease or indigestion, a nervous origin is altogether probable. 
The urine should be frequently examined, in order to guard against 
the possibility of a latent nephritis. The eye-grounds must also be 
carefully investigated with the ophthalmoscope for evidences of cerebral 
tumor, and all the organs of the body, especially the generative appa- 
ratus, should be thoroughly and repeatedly scrutinized. The prognosis 
is usually favorable, unless incurable diseases of the nervous system 
exist. 

Treatment. The treatment must be addressed to the central or 
peripheral causes, so far as they can be ascertained and subjected to 
remedial measures. Temporary relief can be procured by the use of 



FUNCTIONAL DISEASES OF THE STOMACH. 349 

ice and narcotic remedies, especially morphine and atropine hypoderm- 
ically, or hydrate of chloral in doses of a half-drachm when needed. 
Cocaine, bromide of potassium, subnitrate of bismuth, nitrate of silver, 
and the various ethereal preparations sometimes afford relief. If any 
evidence of fermentation appear in the gastric contents, creasote or 
the compound tincture of iodine may be administered with benefit. 
The nausea of pregnancy may sometimes be allayed by sipping very 
hot water, a teaspoonful at a time, whenever the sensation recurs. 

Eructation — Eructatio Nervosa. 

Hysterical and neurasthenic patients not unfrequently experience 
paroxysms of eructation, during which immense quantities of air are 
belched from the stomach, with more or less consequent relief. Some- 
times the occurrence marks the termination of an hysterical paroxysm. 

Rumination — Ruminatio. 

Occasionally the food is regurgitated into the mouth shortly after 
eating, where it may be again subjected to mastication by the patient. 
This event has been rarely observed and described. It occurs more 
frequently among males than among females, and is usually an event 
of childhood or early life. Heredity, imitation, congenital weakness 
of the cardiac sphincter, nervous debility, improper diet, gastrointes- 
tinal catarrh, and any depressing influence that operates upon a deli- 
cate nervous organism may serve to excite the disorder. It is usually 
overcome by attention to the general health, proper regulation of the 
diet, and a serious effort on the part of the patient to resist regurgita- 
tion. 

Sensory Neuroses of the Stomach. 

GrASTRALGIA. 

Etiology. Gastralgia signifies pain located in the stomach, and 
occurring without any discoverable anatomical basis. It occurs most 
frequently among debilitated and chlorotic individuals. Lead poison- 
ing, excessive mental excitement, anxiety, venereal and alcoholic dissi- 
pation are, not unfrequently, antecedents of the disorder. It is not 
uncommon as a consequence of the arthritic diathesis, and during the 
course of malarial infection, or as a consequence of other infective 
diseases. It is often observed in connection with tabes dorsalis 
and other diseases of the nervous system. It may be excited in a 
reflex manner by disorders of the other abdominal or pelvic organs ; 
hence its frequency in uterine and ovarian diseases. Sometimes it 
occurs in connection with chronic diseases of the heart. 

Gastralgia is more common among women than among men, espe- 
cially during the period between the age of puberty and the meno- 
pause. 

Symptoms. Gastralgia sometimes occurs without warning, but fre- 
quently it is preceded by sensations of distention in the stomach, accom- 



350 DISEASES OF THE ALIMENTARY CANAL. 

panied by eructation, nausea, vomiting, headache, and depression of the 
spirits. The pain is often excruciating, and is usually experienced in 
the epigastric region, whence it sometimes radiates between the 
shoulder-blades or over the anterior surface of the abdomen. It is 
aggravated by gentle pressure, but is relieved by firm compression of 
the abdominal wall. The course of the paroxysm is marked by all the 
evidences of intense suffering, and sometimes is associated with faint- 
ness and muscular spasms. The termination of the paroxysm is 
frequently marked by the occurrence of eructation or vomiting. 

The bowels are usually constipated ; the urine is often scanty, and 
throws down an abundant sediment of urates. In hysterical cases the 
conclusion of the attack is marked by a copious discharge of pale urine. 

The duration of the paroxysm is exceedingly variable ; it may recur 
only at long intervals or at stated periods ; and it is sometimes repeated 
several times a day. It is not unfrequent in connection with the cata- 
menial discharge, or as a consequence of mental or physical excitement. 
It is sometimes accompanied by paroxysms of intense hunger, or long- 
ing after extraordinary and indigestible articles of food and other 
strange perversions of appetite. Frequently it alternates with other 
forms of neuralgia or headache. 

Diagnosis. Gastralgia must be differentiated from the following 
diseases: 1. Rheumatism of the abdominal muscles, which is charac- 
terized by a greater continuity of pain that is increased by pressure, 
and is subject to frequent changes of place. Muscular movement also 
increases the pain, and it is diminished by relaxation of the abdominal 
walls. 2. Intercostal neuralgia is marked by the restriction of pain 
to particular intercostal spaces without gastric disturbances. The pain- 
ful points of neuralgia are sometimes also present. 3. Circumscribed 
peritonitis may be recognized by the causes of the affection, by great 
tenderness on pressure over the abdomen, and by the absence of parox- 
ysmal pain. 4. Biliary colic is indicated by restriction of the pain to 
the region of the gall-bladder, by the presence of icterus, and by the 
possible discovery of gall-stones in the stools. 5. Irradiated neuralgia 
sometimes accompanies urinary colic, pleurisy, or pericarditis. 

Prognosis. The prognosis is favorable, though relapses are not 
uncommon. 

Treatment. The treatment must be addressed to the removal of 
the causes of the disorder, and to the relief of pain. For this purpose, 
it will be necessary to ascertain the condition of other organs besides 
the stomach, and to institute their appropriate treatment. Malarial 
neuralgia requires the administration of quinine and arsenic. 

For the relief of a paroxysm of gastralgia a hypodermic injection 
of morphine and atropine must be given, and a large flaxseed-meal 
poultice, sprinkled with a drachm of chloroform, should be laid over 
the epigastrium. Chlorodyne and other narcotics are frequently useful. 
In obstinate cases relief is often procured by syphoning the stomach, 
and washing it out with tepid water. The daily use of electricity, 
with application of the anode to the epigastrium and of the cathode to 
the spine between the shoulders, affords excellent results. 



FUNCTIONAL DISEASES OF THE STOMACH. 351 

Hyperacidity or hypacidity of the gastric juice sometimes occurs 
without the existence of organic diseases that can be recognized. They 
may be relieved by attention to the general health, and by the internal 
administration of alkalies or acids, in connection with bitters and 
tonics. 

Excessive secretion of the gastric juice has been occasionally ob- 
served ; it is indicated by the eructation of an inordinate quantity of 
liquid, attended by heartburn and thirst, without any indications of 
organic disease. Relief may be obtained by daily irrigation of the 
stomach, and by the use of flesh diet. 

Nervous Dyspepsia — Dyspepsia Nervosa. 

Etiology. Nervous dyspepsia occurs during middle life, more fre- 
quently among men than among women. It is usually the consequence 
of excessive cerebral excitement, overwork, dissipation, anaemia, chronic 
organic diseases, prolonged lactation, sexual disorders, and a great 
variety of nervous diseases. Alcohol, tobacco, malaria, uraemia, and 
cholaemia are common causes. 

Symptoms and Diagnosis. Nervous dyspepsia comprises all cases 
of difficult digestion which cannot be referred to actual disease of the 
stomach. It frequently is excited by reflex causes. 

The disorder is attended by considerable uneasiness, that is most 
common after the principal meal of the day, and is prolonged during 
the whole course of digestion. Sometimes there is a sensation of dis- 
tention and pressure in the epigastrium, that is relieved by compression. 
Heartburn and eructation are common. Thirst is increased, and there 
is usually a lack of appetite; sometimes there are perversions of 
appetite. The tongue is clean ; the bowels are constipated, and hyster- 
ical sensations are not uncommonly experienced in the throat, as if a 
ball were moving up and down the oesophagus. There is complaint of 
fulness and dizziness in the head, with noises in the ears, flashes of 
light before the eyes, and a dull headache. The spirits are greatly de- 
pressed, and sleep is disturbed at night, though frequently an inclina- 
tion to sleep after meals is experienced. Sometimes asthmatic sensa- 
tions and attacks of palpitation are experienced. The general health 
and nutrition suffer. 

Treatment. The diet must be judiciously regulated, and a change 
of air and occupation should be secured, if possible. Sponge baths, 
frictions of the skin, massage, and the use of electricity are of great 
value. Great benefit is often obtained in the treatment of neu- 
rasthenic and hysterical patients by the adoption of Weir Mitchell's 
method, which consists in the removal of the patient from home, and 
perfunctory feeding at short intervals with milk, eggs, and broths, for 
which more substantial food is gradually substituted. Daily massage 
and electricity are employed instead of active exercise during a period 
of six or eight weeks. 

Sick Headache — Gastroxynsis. Certain delicately organized indi- 
viduals experience, at stated intervals, a paroxysm which may continue 



352 DISEASES OF THE ALIMENTARY CANAL. 

from one to three days, and is characterized by excessive acidity of the 
stomach, nausea, sometimes vomiting, and severe headache. Relief 
speedily follows evacuation of the stomach by vomiting, or by irrigation 
with the gastric syphon. The treatment must be addressed to the 
general condition ; and, during the course of the paroxysm, may be 
limited to the use of the syphon or the ingestion of a few cups of hot tea. 



CHAPTER VII. 

DISEASES OF THE INTESTINES. 

Acute Catarrhal Inflammation of the Bowels — Enteritis Catar- 

rhalis Acuta. 

Etiology. Acute catarrhal enteritis may be either primary or sec- 
ondary. The primary form of the disease is generally occasioned by 
errors of diet. It is not unfrequently observed after eating indigestible 
substances, or as a consequence of drinking foul water. It may result 
from chilling of the surface when overheated ; or as a consequence of 
wounds, or injuries, or foreign bodies, or parasites in the intestinal 
canal. It may result from the introduction of poisonous substances, or 
from the excessive use of cathartics. 

Secondary catarrhal enteritis results, in many cases, from the exten- 
sion of gastric inflammation into the intestinal canal, or as a conse- 
quence of peritonitis. Rectal inflammation is, sometimes, excited by 
infective secretions from the vagina, or by eczema surrounding the 
anus. 

In many cases the disease is originated, by obstruction in the course 
of the circulation that is produced by disorders of the liver or of the 
intra-thoracic organs. It may also be observed as a consequence of 
consumption, syphilis, chronic nephritis, and other cachectic conditions. 
Frequently it occurs during the course of infective diseases, such as 
typhoid fever, etc. Extensive burns or scalds are frequently followed 
by acute enteritis, and by the formation of round ulcers in the duodenum 
which are identical in nature and origin with the round ulcers of the 
stomach. They are usually located above the orifice of the common 
bile-duct, in the portion of the intestine which is bathed with gastric 
juice from the stomach. 

Pathological Anatomy. The mucous membrane of the intestine 
is red and swelled. Local extravasations of blood are frequently visible 
under the epithelial surface. The muscular and serous coats of the 
intestine remain without change, excepting in very severe cases. The 
solitary and agminated lymph glands are enlarged and prominent, and 
are surrounded by a zone of dilated capillary vessels which forms a 
highly colored areola. The mesenteric lymph glands are also enlarged 
and succulent. Occasionally the epithelial surface appears slightly 



DISEASES OF THE INTESTINES. 353 

eroded, and points of ulceration may be discovered, which, sometimes, 
have their origin in the glandular structures, but, sometimes, affect the 
inter-glandular tissue alone. 

Symptoms. The symptoms of acute catarrhal enteritis are not uni- 
form, but are somewhat modified according to the locality of the inflam- 
matory process. The ileum and the colon are usually associated in 
the disorder, and furnish the most conspicuous symptoms, of which the 
chief is diarrhoea. The bowels are evacuated many times a day, though 
the aggregate amount of fecal discharge may not greatly exceed the 
natural quantity. The stools are more or less fluid, in consequence of 
their rapid passage through the intestines without sufficient time for 
their concentration. There is, frequently, an excessive transudation 
of liquid from the distended bloodvessels of the intestinal canal. 

The stools are yellow, green, slimy, sometimes tinged with blood, and 
contain masses of undigested food, parasites, etc. After a time, they 
become colorless, watery, and turbid with flakes of detached epithelium, 
resembling rice-water in appearance. Fecal odor disappears. 

The abdomen is sometimes distended with gas, but it is often some- 
what retracted. The peristaltic movements of the intestines can be 
readily distinguished through the abdominal wall, and are accompanied 
by gurgling sounds and colicky sensations. The urine is usually 
diminished, and, in severe cases, may be completely suppressed. It is 
highly concentrated, and frequently occasions a burning sensation in 
the urethra. 

Febrile symptoms are frequently absent, but sometimes there is con- 
siderable elevation of temperature which may persist for a number of 
days, rendering the diagnosis doubtful between enteritis and typhoid fever. 

Thirst is increased. The appetite is generally diminished, though, 
sometimes, it is retained if only the lower portion of the bowels be 
involved. The disease may last for one or two days, or it may con- 
tinue for many weeks. Sometimes it terminates in collapse and death. 

When acute inflammation involves only the upper portion of the 
intestine the bowels may remain constipated in consequence of the 
absorption of the liquid portion of the feces as they pass through the 
healthy colon. The principal symptoms are of a colicky character. 
Jaundice is not unfrequently present, by reason of an inflammatory 
obstruction of the common bile-duct. 

Inflammation of the ccecum and vermiform appendix are not uncom- 
mon as a consequence of irritation by foreign bodies. The principal 
symptoms are pain, swelling, and dulness on percussion in the right 
iliac fossa. 

Catarrhal inflammation of the rectum (proctitis catarrhalis) is indi- 
cated by tenesmus, and by the frequent passage of small quantities of 
slimy and bloody matter, with a certain amount of tenderness on pres- 
sure in the left iliac region. The anus is strongly retracted, and 
exhibits spasmodic movements of the sphincter. The mucous mem- 
brane of the rectum is hot and swollen, and is covered with an exces- 
sive amount of bloody mucus. In chronic cases the sphincter becomes 
paralyzed, and the irritating contents of the bowels continually trickle 
through the anus, and produce excoriation of the adjacent surfaces. 

28 



354 diseases :<i :hz al:mi>ta = y ;a>"al. 

Diags sis ami Prognosis. Acute catarrhal enteritis can hai 
be mistaken for anyth ing bat I fern in febrile ases 

when that isease is t Lent From the last it may be iistinguished 
b y the t : .. silli in die stools; and from the first, by 

the course of the temperature, and by the absence of re seol d i typhoid 
li Fhepi _ sis unless complicated by ther incur- 

able discs sea 

Trratmkht. The patient must remain in bed and the abdomen 
should be covered no :■: -red meal poult: sea. Tie diet should 

e restri 3te to gruel and mutton broth. Boiled water and a little red 
wine may be dlowed for a drink. I: the " ^h - een prece led by 
msti] don >f the iwels :: by errors in diet, a tablespoonful or two 
: sastoi »il maybe given in the froth of beer, :; sonceal its taste 
ben - ke it re lil ::.. little milk in which a stick of cinnamon 
hs - een nled. If oil is :':;e::::nable. the bowels may be e 
with small lose :: salomel and jal alomeL, pulv. jalap., aa a 
If the liarrhosa loes not readily subside, Dover's powder may be gi 
;;. i;srs :: ~ t grains every three hours; :r the subnitrate. or salicy- 
late, :: bismuth, in ten-grain doses, with half a grain of 

_. every :hree h<:urs. If the lisease tends :: become chronic in 
the lower bowel, it is well :: employ a daily irrigation of the colon, 
with the lid : fountain ay ringe ind rectal catheter. The intes 
_ ; - be thus thoroughly washed ml ind then inje ith a very 

weak solution of nitrate of silve: 1 : : "JO). 

Tenesmus m ay be relieved by suppositories of morphine and bella- 
donna (morph. sulph.. gr. J, ext. bellad:^.. gr. J, olei coco., q. s. Ft. 
suj -Ti-rium no. i). 

Acute Infantile Gastro-enteritis — Gastrc-enteritis Acuta Catarrhalis 

Infantum. 

Etiology. Thiring ho: weather the children in large - are 

smely liable : inflammation of the stomach and u 

that is aused by improper diet, insufficient clothing during sudden 

:\ chilling of the sv 
crowding, and the miasm which pervad - lensely populated and ill- 
drained quarters. In additi a to the rants are 
deprived i nourishment in consequence of the debility, illness, 
or death of their mothers. The infantile stomach is. more 

sed 1 liseas cons F its in relopmenfl 

:i of which it is unfitted for anything but food of the normal 

quality and quantity. The p. essea ag and dentition are, 

•led with danger because of the difficulties that accompany 

•f food to which the child is imperfectly adapted, and by 

- n of the general disturbance which frequent" s the eruption 

of the teeth. 

Pi [Y. The anatomical changes which accom- 

pany infantile diarrhcea do n iffer from those which 

have been alread ed. 

Symptoms The attack commences with 



DISEASES OF THE INTESTINES. 355 

and diarrhoea by which the contents of the alimentary canal are 
evacuated. Sometimes the little patient passes rapidly into a condition 
of collapse, and death follows, although the active manifestations of the 
disease have previously subsided. Under ordinary circumstances, 
however, the bowels continue to be moved about once every two hours. 
The stools are, at first, slimy, and yellow or green, or they assume 
that color after exposure to the air. Gradually they become trans- 
formed into a dirty, watery liquid which contain masses of curdled 
milk and flakes of mucus that are sometimes stained with blood. The 
stools lose their offensive odor and become transformed into a rice- 
water liquid which scarcely stains the diaper. 

The separate discharges are preceded by colicky pain, during which 
the infant cries and draws up its knees against the belly, seeming to 
obtain relief from their pressure. The abdomen may be either dis- 
tended or it may be considerably collapsed. The anus is surrounded 
by a broad, red ring of eczema intertrigo. Sometimes there is prolapse 
of the rectum. The urine is greatly diminished or entirely suppressed. 
There is great thirst, and the child nurses or drinks eagerly, but 
usually vomits everything that is taken. The mouth is dry and hot, 
and often exhibits patches of thrush or aphtha. The breath exhales 
an acid or offensive smell. Symptoms of collapse usually appear in 
the course of twenty-four or forty-eight hours. The extremities 
become cold, emaciation is extreme, the eyes sink in their sockets, 
the countenance assumes an aged and careworn expression, the fonta- 
nelles become greatly depressed, and in very young children the cranial 
bones may overlap one another. Catarrhal inflammation attacks the 
conjunctiva ; the cornea is sometimes perforated by ulceration. Symp- 
toms of cerebral anaemia appear in the form of dyspnoea, spasms, 
delirium, convulsions, coma, and death. 

Prognosis and Treatment. The prognosis is always very grave. 
Cholera infantum is an exceedingly dangerous disease. 

Of the greatest importance is prophylactic treatment in all cases of 
artificial feeding, weaning, and dentition. All women are not fitted to 
nurse their children ; young girls of less than eighteen years, chlorotic 
and consumptive mothers, or the victims of nervous disease and syphilis, 
should not be allowed to act as nurses. Healthy women should be 
instructed during the later weeks of pregnancy to bathe their nipples 
with cologne- water or whiskey, and should rub them with a piece of 
soft flannel, in order to prevent the danger of fissures and ulceration 
during the period of lactation. The babe should be nursed at regular 
intervals, every two hours during the first month of life ; afterward 
every three hours during the day. Its mouth should be carefully 
washed after nursing, in order to prevent fermentation of milk within 
its cavity, by which indigestion and diarrhoea might be excited. The 
mother's diet must be sufficiently abundant without the use of vegeta- 
bles and acids. Renewed pregnancy must be the signal for weaning 
the child, since the mother's milk will then become deficient in 
nutriment. 

If it be necessary to employ a wet-nurse, the utmost caution must be 
exercised in the selection of a healthy woman who is free from syphilis. 



356 DISEASES OF THE ALIMENTARY CAXAL. 

A mother Avho has given birth to other children should be preferred, 
because of her superior skill in the management of infants, and her 
own child should not differ more than one or two months in age from 
the nursling. 

If it be necessary to resort to artificial feeding, cow's milk affords 
the best substitute for mother's milk, though ass's milk and goat's milk 
are theoretically preferable. Milk should be procured from a healthy 
cow, especially from one that is free from every symptom of tubercu- 
losis. The animal should be stall-fed with hay, oats, meal, and simi- 
lar food. Green food is objectionable, since its use often exercises 
through the milk a laxative effect upon the infant. 

The milk should be heated to 200° F. as soon as it is obtained, 
and should be neutralized with one or two tablespoonfuls of lime- 
water, or a small quantity of bicarbonate of sodium. A convenient 
sterilizing apparatus for the preparation and storage of milk may be 
very readily obtained from any dealer in medical and surgical supplies. 
The nursing-bottle must be kept scrupulously clean, and empty when 
not in use. During the first month of infantile life the milk should be 
diluted with an equal part of warm water which has been previously 
boiled. With each successive month the quantity of water may be 
diminished by one-fifth, until pure milk is reached. It should be 
given at the temperature of the body, after it has been sweetened with 
milk-sugar, if that can be obtained, or otherwise with common white 
sugar ; a very little salt may also be added to the mixture. Artificial 
substitutes for milk should, if possible, be avoided, since their use pre- 
disposes the infant to rickets and allied disease. 

At the end of the ninth month a healthy child may be prepared for 
weaning, though it is well to delay until the summer is passed, and to 
avoid a time when the eruption of teeth may be expected. The milk 
should be mixed with an increasing quantity of thin broth, which, after 
a while, may be reinforced with the white ot an egg, and the child may 
be gradually accustomed to finely minced meat, and to a little stale 
bread, with thin cocoa for a drink. 

If, in spite of all these precautions, the infant be attacked with diar- 
rhoea, the ordinary food must be withdrawn, and the child may be 
allowed to take in teaspoonful doses water that has been boiled and 
cooled and mixed with the white of a fresh egg in the proportion of 
one egg to a half-pint of water. A small quantity of salt should be 
dissolved in the water, and, if the patient seem exhausted, a teaspoon- 
ful of brandy, or a corresponding quantity of good wine, may be added. 
Thin arrowroot, sago, and cream are sometimes agreeable articles of 
diet; mutton-broth and beef-tea, made by expression of the juice from 
minced meat that has been soaked in an equal quantity of hot water, 
may be allowed. 

For the relief of vomiting and diarrhoea, calomel should be given 
until the stools become slimy and bilious : 

R . — Calomel. g r -j- 

Saoch. lact gr. x. — M. 

F. pulv. no. x. S. — One every hour. 



DISEASES OF THE INTESTINES. 357 

This may be followed by a neutralizing cordial, in doses of ten to 
fifteen drops every hour. With the subsidence of acute symptoms, 
recourse may be had to astringents : 

H . — Tr. krameriae ) z M A/r 

i . , > .... aa £ss. — M. 

cyr. rnei aromat. J ° 

S. — Fifteen drops every two hours. 

Or bismuth — 

K .—Bismuth, subnitrat gr. ij. 

S. — Every three hours. 

Opiates should be avoided, since a fatal result often follows their admin- 
istration to young children. 

Convalesence is, frequently, very rapid, and requires little medicine, 
if a proper diet can be procured. Change of air from the city to the 
country, or to the seaside, or to the great lakes, is attended with the 
happiest results. 

Chronic Catarrhal Inflammation of the Bowels — Enteritis 
Catarrhalis Chronica. 

Etiology. Chronic catarrhal inflammation of the bowels may 
result from an acute inflammation, or it may gradually invade the 
intestines as a consequence of progressive obstruction in the course of 
the abdominal circulation. It is, not uncommonly, associated with 
general cachetic conditions and tubercular or malarial infection. In 
certain localities infusorial parasites act as an exciting cause of the 
disease. 

Pathological Anatomy. The mucous membrane is dark and 
livid, sometimes, in chronic cases, of a slate color, produced by the deposit 
of blood-pigment in the tissue. This is most abundant in the villi and 
around the circumference of the lymph follicles. These glands are, 
usually, considerably enlarged, and the entire mucous membrane, with 
the submucous connective tissue, is greatly thickened. In severe cases 
the whole thickness of the intestinal wall participates in the hyperplastic 
process. The surface of the membrane is covered with a slimy or, 
sometimes, puriform liquid. The mucous membrane is eroded and 
ulcerated. The ulcers are, at first, rounded, but finally assume an 
irregular form with undermined borders ; polypous growths are not 
uncommon in their vicinity. Not unfrequently the surface of the ulcer 
yields pus ; and, sometimes, large vessels become eroded and bleed. In 
other cases, perforation and peritonitis occur. Sometimes the danger 
of perforation is obviated by the formation of adhesions between the 
peritoneal base of the ulcer and a neighboring peritoneal surface. 

Circumscribed abscess may thus be formed. It sometimes attains to 
formidable dimensions, and may be evacuated through any one of the 
adjacent cavities or passages. 

In favorable cases the ulcer heals by cicatrization ; but this process 
may originate new dangers by constriction of the intestinal canal. 

Follicular ulcers originate in the lymph follicles of the intestines, 



358 DISEASES OF THE ALIMENTARY CANAL. 

and are usually situated in the colon, which sometimes appears com- 
pletely riddled by their multiplicity. The process of ulceration is indi- 
cated by swelling and multiplication of the glandular cells, which then 
undergo degeneration and necrosis as a consequence of mutual pressure. 
The cavity that is thus formed rapidly enlarges by ulceration of the 
surrounding mucous, tissue. The undermined walls and ulcerated cavi- 
ties frequently contain translucent, jelly-like masses, resembling sago 
grains, which are frequently voided with the stools. The subsequent 
course and results of follicular ulceration correspond with the similar 
conditions which have been previously described. 

Symptoms and Diagnosis. The bowels are usually constipated or 
irregular in their action, being alternately either confined or loosened. 
Sometimes diarrhoea is manifested only on arising in the morning, when 
two or three loose passages occur, without subsequent evacuation until 
the next morning. In many instances, undigested food mixed with pus 
or sago grains may be observed in the stools. Sometimes blood appears 
in small quantity. Microscopical examination indicates the exact 
character of the evacuations, and may render evident the eggs of para- 
sites, or infusoria. 

In certain cases, casts, or voluminous shreds of fibrillated mucus, 
which appear like fragments of detached mucous membrane, are evac- 
uated from the bowels (enteritis membranacea). Such discharges some- 
times recur at stated intervals with considerable regularity. They are 
usually observed during middle life, especially in women with blue eyes, 
fair complexion, and a nervous temperament. 

Flatulence, gurgling, and colicky pain are frequent occurrences in 
chronic catarrhal inflammation of the bowels. Sometimes palpitation 
of the heart, subjective dyspnoea, and headache accompany the disease. 
If the stomach is also involved, the symptoms of chronic gastritis are 
present. 

Progressive emaciation and exhaustion are gradually developed. The 
patient becomes hypochondriacal and liable to mental disorder. The 
blood is reduced in quantity, and its circulation is so enfeebled that the 
surface of the body becomes cool and pale, and the extremities remain 
cold. 

The duration of the disease covers many months or years. Death 
results from cardiac failure, or from intercurrent diseases. 

Prognosis and Treatment. Chronic catarrhal inflammation of 
the bowels is a very obstinate disease, and its prognosis is rather unfa- 
vorable, on account of the difficulty with which patients can be sub- 
jected to radical treatment at a sufficiently early period. 

When constipation exists, the bowels should be relieved by the daily 
use of compound rhubarb pills, or compound licorice powder, or 
podophyllin in doses of one-quarter of a grain, or tamarind laxatives. 
Glycerin suppositories sometimes produce a good effect : and mineral 
waters, such as Saratoga spring water, Hunyadi-Janos water, Friedrich- 
shall and Seidlitz waters, may be taken with great benefit on arising in 
the morning. Massage, and the application of the faradic current to 
the walls of the abdomen are of great service. 

Chronic catarrhal inflammation that is accompanied by diarrhoea 



DISEASES OF THE INTESTINES. 359 

must be treated in accordance with the rules which have been given for 
the management of the acute form of the disease. 

Inflammation of the Caecum and Vermiform Appendix — Typhlitis, 
Peri- et Paratyphlitis. 

Etiology. The inflammations of the caecum and vermiform ap- 
pendix are described under the name typhlitis ; while inflammation of 
the peritoneum which surrounds that portion of the bowel is called 
perityphlitis ; and inflammation of the connective tissue behind the 
caecum is known as paratyphlitis. Such inflammations are generally 
caused by coprostasis, or by foreign bodies, such as seeds, stones, etc., 
and by ulcers which have been formed upon the mucous membrane. 
Sometimes the process thus excited is restricted to the vermiform ap- 
pendix. 

Paratyphlitis and perityphlitis are usually excited as a secondary 
consequence of inflammations either within the bowel or in the neigh- 
boring organs. They sometimes occur in connection with infective 
diseases, and are more frequently encountered among men than among 
women, especially during early adult life. 

Symptoms. The different forms of inflammation which affect the 
caecum and its environment agree in the common symptoms of pain 
and swelling in the right iliac fossa. They sometimes commence in- 
sidiously, but often originate suddenly. There is complaint of intoler- 
able pain in the right iliac fossa, that is increased by all forms of 
movement or pressure. The patient lies upon the right side, with the 
back bent forward, and the right thigh drawn upward, so as to relax 
the abdominal wall. Examination of the abdomen discovers in the 
right iliac region more or less swelling that is produced by a resistant 
tumor of a long oval form, occupying the position of the caecum and 
commencement of the ascending colon. The abdomen is often dis- 
tended with gas, the bowels are constipated, the urine is scanty, some- 
times there is a high fever and a small, hard and rapid pulse. The 
countenance indicates pain, and the eyes are sunken. Sleep is dis- 
turbed, and the speech is reduced to a whisper. Hiccough is frequently 
observed, vomiting often occurs, and sometimes assumes a fecal char- 
acter, and the breath is offensive. If the symptoms have been pro- 
duced by fecal accumulation, they soon subside after evacuation of the 
bowels; but it often happens that chronic inflammation, ulceration, and 
cicatrization produce lasting injury to the patient. 

Inflammation of the vermiform appendix is usually attended by 
more acute symptoms. Fecal vomiting is absent; the tumor is usually 
smaller than in fecal typhlitis; and perforation, followed by peritonitis, 
frequently brings on a fatal termination ; sometimes ulceration occurs, 
and is followed by cicatrization. The orifice of the appendix may be 
thus occluded, after which event the tube becomes distended with a 
serous liquid (hydrops processus vermiformis). 

In cases of paratyphlitis the tumor in the right iliac fossa is fre- 
quently concealed by intestinal folds that are filled with air and mask 
its dulness on percussion. Great pain is experienced, and it fre- 



360 DISEASES OF THE ALIMENTARY CANAL. 

quently irradiates into the shoulder or into the right thigh. The right 
testicle is sometimes retracted, and painful passage of urine is ex- 
perienced. 

The products of inflammation are removed by absorption in favor- 
able cases ; but sometimes the exudation burrows behind the peritoneum 
into the vicinity of the kidney, or within the cavity of the pelvis, when 
the bladder, uterus, vagina, or rectum may be perforated. Sometimes 
the abdominal wall is thus penetrated, and pus escapes externally. In 
other cases the thoracic cavity may be reached. Not unfrequently a 
paratyphlitic abscess ruptures into the caecum and is evacuated through 
the bowels. 

Simple perityphlitis is characterized by the predominance of the 
symptoms of peritonitis. The iliac tumor lies very superficially, and 
is exceedingly sensitive. Suppuration may lead to the evacuation of 
pus externally, or to its escape into the internal organs. Large blood- 
vessels are sometimes thus eroded, and occasion dangerous internal 
hemorrhage. Intestinal obstruction by compression of the ileum, or 
as a consequence of inflammatory paralysis of its muscular coat, is not 
uncommon. An indurated tumor frequently remains for a long time 
after the subsidence of acute symptoms, and relapses frequently occur 
on slight provocation. 

DIAGNOSIS. The diseases which may be mistaken for inflammation 
of the csecum and its environment are: 1. Coprostasis in the ccecum. 
which may be recognized by the absence of inflammatory symptoms. 
2. Cancer of the intestine, usually insidious in its development and 
course, and encountered among old people. 3. Invagination, which is 
indicated by a tumor, accompanied by a bloody and slimy diarrhoea. 
4. Wandering kidney, which may be recognized by the renal form of 
the swelling ; by its mobility ; and sometimes by the pulsation of its 
artery. 5. Biliary and renal colic, characterized by intermittent pain 
and by the presence of icterus, or of hrematuria. 6. Psoas abscess 
and tuberculosis of the pelvic bones may be recognized by the evidence 
of disease in the spinal column or pelvis. 7. Psoitis, indicated by 
pain in the right iliac fossa, but unattended by disturbances of the 
gastro-intestinal canal. 8. Tubercular or cancerous diseases of the 
mesenteric or retro-peritoneal lymph glands, characterized by multiple 
tumors of irregular form and changeable location. 

Prognosis. Typhlitis is less dangerous than the other forms of 
inflammation about the caecum. All are attended with danger, espe- 
cially if perforation should occur. 

Treatment. In typhlitis that is dependent upon fecal accumula- 
tion, the intestine should be thoroughly irrigated, every hour, by the 
aid of a fountain syringe, until fecal evacuation takes place. This 
gives a better result than the use of purgatives, which are liable to 
excite inflammation. In cases of inflammation involving the appendix 
vermiformis, and in para- or peri-typhlitis, the patient must remain in 
bed with a large warm poultice over the abdomen, and must be placed 
under the influence of opium (half a grain every hour until the pupils 
become contracted). The diet must be restricted to liquids, and the 
opium treatment must be continued for weeks, if necessary. The colon 



DISEASES OF THE INTESTINES. 361 

may be irrigated every day by the aid of a fountain syringe. Severe 
pain can often be promptly subdued by the application of several leeches 
over the seat of the tumor. In cases of tardy absorption of the 
products of inflammation, mercurial ointment may be gently rubbed 
into the skin over the region of swelling. If fluctuation be detected, 
an early incision should be performed. 

Intestinal Cancer — Carcinoma Intestinale. 

Pathological Anatomy. Intestinal cancer usually occurs as a 
primary disease. In the majority of cases it is developed in the rectum 
near its junction with the sigmoid flexure, and in the other convolu- 
tions of the large intestine ; but it is rarely discovered in the small 
intestine. When that portion of the canal is invaded, it is usually the 
duodenum which becomes infiltrated. All the different varieties of can- 
cerous disease are found in the intestine as well as in the stomach, and 
the general appearance of the neoplasm depends upon its histological 
structure. 

The disease manifests a tendency to encircle the intestinal canal, and 
thus to produce constriction or complete occlusion. Originating in the 
mucous membrane, the entire walls of the canal are finally infiltrated. 

When the intestine has been constricted by cancerous infiltration, the 
portion of the canal above the stricture becomes dilated and filled w T ith 
stagnant feces, while the portion below the stricture falls into a condition 
of collapse and innutrition. The mucous surface exhibits evidences of 
inflammation and ulceration. Sometimes actual rupture of the dilated 
, portion takes place. Occasionally, portions of a soft cancerous growth 
are thrown off, and may be recognized in the feces ; partial cicatrization 
may also follow such an event. 

The degeneration of a soft cancer is often followed by hemorrhage, 
or by rupture into the peritoneal cavity, or by the establishment of 
passages communicating with the bladder, or with the vagina, or with 
the adjacent loops of the intestine itself. Sometimes the abdominal 
wall may be perforated, or fecal abscesses may be formed behind the 
peritoneum. The lymph glands and neighboring organs may also 
become secondarily invaded by cancerous infiltration. 

Symptoms. The symptoms of intestinal cancer are often exceedingly 
obscure. There may be complaint of abdominal pain, irregularity of 
the bowels, with alternating constipation and diarrhoea, gradual emacia- 
tion, and death from exhaustion, which is only explained after decease 
by the discovery of intestinal cancer. 

Sometimes, obstruction of the bowels occurs suddenly, and is ex- 
plained by the lodgment of undigestible substances above the cancerous 
constriction. 

Cancerous infiltration of the lower portion of the colon is often 
ushered in by an unendurable pain under the sacrum, resembling that 
of sciatica. 

Abdominal exploration may be accomplished by external palpation, 
or by rectal examination, or by the combination of both methods. 
When a tumor can be distinguished through the abdominal wall, it gen- 



362 DISEASES OF THE ALIMENTARY CANAL. 

erally presents an irregular, oval, or rounded form : it is generally sen- 
sitive and movable, but sometimes it cannot be displaced, especially 
if it be developed in the crecuin, or if it has become adherent to the 
adjacent surfaces. When the transverse colon or other loops of the 
intestine have been invaded, it is often exceedingly movable. For 
this reason the majority of intestinal cancers appear to lie below the 
level of the navel. 

Rectal exploration is most useful in cases of rectal cancer, or when 
the sigmoid flexure is infiltrated. Under such circumstances, uneven, 
slimy, bloody, and ulcerated surfaces may often be detected, or scir- 
rhous indurations may be clearly defined. So far as possible the 
exploration should be effected by the aid of the finger, since instrumental 
examination occasions great pain. 

The feces exhibit considerable change in quantity, form, and consti- 
tution ; in the majority of cases obstinate constipation is the rule. 
Sometimes the progress of ulceration brings relief when an obstructive 
mass breaks down. 

The feces are sometimes flattened, ribbon-like, or reduced to small 
lumps, like sheep's dung. Sometimes, an excessive hemorrhage takes 
place, or the stools may contain muco-purulent masses mixed with can- 
cerous fragments. 

"When the duodenum is invaded by a cancerous growth, persistent 
jaundice follows occlusion of the common bile-duct, and the symptoms 
of gastric and oesophageal dilatation may appear, if the lumen of the 
intestine be seriously obstructed. 

Rectal cancer is not inconsistent with long preservation of the general 
health. Evacuation of the bowels, however, is attended with great 
pain, and sometimes assumes the form of diarrhoea. Hemorrhoids 
are frequently developed, and must not be mistaken for cancerous 
masses. 

The duration of intestinal cancer is about four years. Death fre- 
quently occurs as a result of progressive emaciation and exhaustion. 
The limbs become cedematous ; sometimes thrombi obstruct the veins, 
and lead to a fatal result. In certain instances death is directly caused 
by secondary cancerous growths which involve the vital organs. In 
other cases, it is the consequence of intestinal occlusion or of perfora- 
tion ; it may be preceded by fecal abscess and pyemic symptoms. 

Diagnosis and Prognosis. Cancerous disease of the sigmoid flexure 
and rectum are the only forms of intestinal cancer which admit of easy 
recognition. Even when a tumor can be discovered through the abdom- 
inal wall, it is often impossible to decide whether it be connected with 
the pancreas, the liver, the lymph glands, the kidneys, the peritoneum, 
or the intestine. The prognosis is always unfavorable. 

Treatment. The active treatment of intestinal cancer falls within 
the realm of surgery : but when the patient will not submit to opera- 
tion, or when surgical interference is not indicated, the principal duty 
of the physician is limited to the prescription of a liquid diet consising 
of milk and other animal food, together with opiates in quantity suf- 
ficient to relieve pain. Offensive discharges from the anus require the 
daily use of disinfectant injections. 



DISEASES OF THE INTESTINES. 363 

Among other intestinal tumors have been described cases of lipoma, 
angioma, myoma, sarcoma, and cystoma. Polypous growths sometimes 
form in the rectum, especially among children who have suffered with 
diarrhoea. Such tumors frequently excite a chronic discharge of blood 
from the rectum, and are sometimes extruded spontaneously through 
the anus. A chronic or bloody diarrhoea in the case of a child should 
always arouse suspicion of the existence of a polypus in the rectum. 

Intussusception — Invagination. 

Pathological Anatomy. Intussusception consists in the entrance 
•of one portion of the intestine within another. This sometimes takes 
place as a simple mechanical movement during the act of death, but in 
such cases there are no evidences of inflammation. 

In certain cases the lower portion of the intestine is pushed upward 
within the superior portion of the loop, constituting an ascending or 
retrograde intussusception. In the majority of cases, however, the 
upper segment is received within the lower, thus constituting a de- 
scending or progressive intussusception. The invaginated portion is 
called the intussusceptum, while the invaginating sheath is called the 
intussuscipiens. Besides the intussusceptum, a portion of the mesentery 
becomes invaginated within the sheath ; consequently, its traction causes 
the lower orifice of the invaginated portion to present the appearance 
of a longitudinal slit instead of a circular opening. 

The neck of the invaginated portion tends to become more and more 
constricted by the occurrence of inflammation, hence the portion of the 
intestine above the stricture dilates, through the accumulation of feces, 
which by their weight tend to crowd the intestine deeper into the 
invaginating sheath. In this way the intussusceptum may reach the 
anus, and may even project through that opening. 

As a consequence of the great disturbances of circulation that accom- 
pany the process of invagination and constriction, inflammation is 
established, so that the intussusceptum may become gangrenous, actually 
sloughing off and being discharged through the anus. In this way it 
is recorded that not less than ten feet of the intestine were discharged 
in one instance. Such a process may be very readily accompanied by 
hemorrhage or by peritonitis or by inflammation of the intestine. If 
life be preserved, there is great danger of subsequent constriction of 
the intestine as a result of cicatrization. 

Intussusception takes place more frequently in the ileo-csecal por- 
tion of the intestine than anywhere else. The ileum descends with 
the caecum into the colon, constituting ileo-ccecal intussusception. 
When the ileum alone descends through the ileo-csecal valve, it is 
termed ileo-colic intussusception. 

Etiology. About half the cases of intussusception occur during 
infancy and early childhood. It may be produced by falls or blows 
upon the abdomen, or by constipation or diarrhoea. Occasionally it is 
caused by the weight of an intestinal tumor. 

Symptoms. Intussusception excites great pain, which, among chil- 
dren, frequently induces convulsions. It is sometimes accompanied by 



: : - 1 a - z - . .-.:_::■: i y t a :-. y :.,xa:, 

thin, slimy, and blot ly six Is. J ■r/nus and vomiting are not uncom- 
mon. The abdomen becomes, after a time, sensitive to pressure and 
greatly distended Frequently a firm, elastic, smooth, and sausage-like 
mass can be felt in the neighborhood of the right iliac fossa, extending 
toward the navel or across the entire width of the belly. Frequently 
the anus remains gaping open and oozing with slimy stools. With the 
finger in the rectum, it is frequently possible to feel the invagin 
mass. Replacement of the intussusceptum is followed by the spc 

rry of the patient : but. unfortunately, relapses are very common. 

In severe cases the diarrhoea which marks the commencement of 
..'" _: nation is followed by the symptoms of complete obstruction of 
the intestine and cessation of the discharge. Evidences of peritc 
usually appear, and death is preceded by complete collapse, or by the 
convulsions which indicate cerebral amentia. 

Sometimes the separation and evacuation of an intussusceptum 
effects a spontaneous cure. This event usually takes place daring the 
later part of the second week, or during the third week after the 
commencement of the disease. 

Diagnosis. The diagnosis generally presents no difficulty and is 
based upon the symptoms that have been described. The differential 
diagnosis may lie between an intussusceptum and a rectal polypus, but 
the decision should not be difficult. 

Prognosis. About seventy per cent, of the cases of intussusception 
prove fatal. 

Treatment. Intestinal insussusception requires the administration 
of large doses of opium | half a grain every hour until the pupils become 
contracted . Infants may be given one or two drops of the tincture of 
opium every hour, so long as it can be tolerated. Three or four times 
a day the lower bowel should be filled with tepid water from a fountain 
syringe But. when the case has continued for any length of time, 
great caution should be exercised in the use of injections for fear 
of rupture of the intestinal wall. Inflation of the colon with gas has 
been attempted by the aid of a bellows and rectal tube, or by the libera- 
tion of carbonic acid gas above the sigmoid flexure, but this operation 
has been followed, sometimes, by intestinal rupture. If the tumor can 
be reached through the anus, an effort should be made to replace it by 
the aid of a bougie. The question of abdominal section for the relief 
of intussusception may arise : but. hitherto, the results of the operation 
have not been encouragii _ 

Intestinal Constriction and Occlusion — Enterostenosis et Ileus. 

Etiology. Constriction or occlusion of the intestine may result 
either from changes in the contents of the alimentary canal, or from 
alterations in the structure of its wall, or in the com: oeighbor- 

They may be produced by when the cavity of 

the intestine is occupied by hardened fecal matters. In other eases 
/ gall-e 3j enteroliths, parasites, and insoluble 

substances which have been swallowed may obstruct the lumen of the 
canal. 



DISEASES OF THE INTESTINES. 365 

The growth of tumors in the intestinal wall and the development of 
cicatricial indurations may obstruct the passage. In this way syphilitic 
processes and haemorrhoids may constrict the rectum. Obstinate con- 
stipation which has been produced by nervous disorders may lead to 
obstruction. In like manner, injuries of the abdomen, inflammation 
following the reduction of a hernial tumor, intussusception, or twisting 
of the gut may result in occlusion of the bowel. 

Obstruction may sometimes be produced by internal hernia, as when 
a loop of the intestine finds its way through an abnormal opening in 
the mesentery or the suspensory ligament of the liver, or the round 
ligaments of the uterus, or is pushed through the foramen of Winslow. 
After peritonitis loops of intestine are sometimes incarcerated by the 
bands of adhesion which have been thus formed. 

Among the diseases of neighboring organs by which the intestine 
may be constricted or occluded, must be mentioned tumors involving 
the pelvic and other abdominal organs, ivandering kidneys, peritoneal 
exudations, and fecal accumulations which, by their pressure, may 
constrict portions of the intestinal canal. 

The disease occurs more frequently among men than among women ; 
all ages are liable to its incidence ; it is more frequently encountered 
among Russians than among other Europeans, in consequence of the 
greater length of the Russian intestine. 

Pathological Anatomy. Above the point of constriction the 
intestine becomes dilated, while the lower portion presents a collapsed 
appearance. Duodenal constriction leads to dilatation of the stomach 
and oesophagus. In chronic cases the intestinal wall becomes thick- 
ened, and its muscular layer exhibits considerable increase. Tissue 
degeneration and rupture may finally occur, however, in chronic cases. 
The mucous membrane of the dilated portion is inflamed and often 
ulcerated through mechanical irritation by scybalous feces. Peritonitis 
is a not uncommon event, especially after perforation. If vomiting 
occur it may lead to pneumonia through the intrusion of vomited matters 
into the trachea and bronchi. 

Occlusion, as a consequence of torsion, usually occurs in the neigh- 
borhood of the sigmoid flexure. 

Symptoms. The symptoms of intestinal constriction are frequently 
characterized by extraordinary difficulty in voiding the stools, especially 
if the diet has been composed largely of vegetable substances. In many 
cases, however, there is a chronic diarrhoea that is produced by inflam- 
mation of the intestine above the point of stricture. This is often 
observed in syphilitic or cancerous strictures of the rectum. The feces 
are frequently flattened and ribbon-like, or resemble sheep's dung. 
Defecation is usually attended with great pain, especially when the 
lower part of the colon or the rectum are involved. Haemorrhoids, in 
such cases, are exceedingly common. The abdomen is usually distended 
with gas and feces. Sometimes active peristalsis is apparent, and 
gurgling sounds are audible in the gut. 

Careful examination through the rectum and the vagina should never 
be neglected. Constrictions of the small intestine lie in the region 
between the navel and the pubes. Obstructions of the colon are seated 



366 DISEASES OF THE ALIMENTARY CAXAL. 

either in the lateral portions of the abdomen or above the navel. 
Obstructions which are produced by diseases of the pelvic organs can 
be frequently discovered through the vagina. Rectal examination by 
the introduction of the whole hand under chloroform should seldom be 
attempted, by reason of the danger of rupture which has been, in 
several instances, thus produced. 

Complete occlusion of the intestine has been described under several 
titles, viz.. Ileus. Miserere. Passio-iliaca, Volvulus. Of these the first 
is the most ancient and convenient. 

Ileus is indicated by three principal symptoms: absence of defeca- 
tion, arrest of flatus, and the occurrence of fecal vomiting. The 
explanation of the first and second symptoms is obvious. The vomited 
matters consist of partly digested food, granular detritus, fungous para- 
sites, and fecal masses, which at first present a normal appearance, but 
which, after a time, are reduced to a thin, watery, offensive liquid. 
The abdomen becomes distended with intestinal gases ; peristaltic move- 
ments are frequently visible ; and loud borborygmi are distinctly audi- 
ble. Sometimes dulness and resistance like that of a tumor can be 
distinguished. The urine is greatly reduced in amount, and contains 
indican when the small intestine is occluded, because indol is then 
absorbed from the upper intestine and is excreted through the kidneys 
in the form of indican. 

The patient rapidly passes into a condition of collapse. The tempera- 
ture is sometimes increased, but it is often subnormal. The pulse is 
usuallv small and rapid. Death sometimes occurs within a short time, 
as if by shock. In other cases, though rarely, life is prolonged in a 
state of misery for many weeks. The fatal termination may sometimes 
occur suddenly, as a consequence of suffocation through the entrance of 
vomited matters into the respiratory passages. Intestinal rupture and 
peritonitis may be developed and prove fatal. Occasionally, the 
abdominal wall is perforated, and thus a contra-natural anus is formed, 
or a loop of the intestine above the point of constriction may become 
adherent to the loop below the obstruction, and by perforation at the 
point of adhesion relief may be obtained. In other instances, perfora- 
tion may evacuate the intestine into the peritoneal cavity, or into other 
cavities or organs of the body. Fecal abscess and pyaemia may also be 
developed. In rare instances, a spontaneous recovery takes place 
through the evacuation of foreign bodies or other obstructing ma- 

Diagnosis. The location of the intestinal obstruction is not always 
easy to discover. The indications derived from the presence or absence 
of indican in the urine are only decisive in the absence of periton. 
cancer, both of which diseases cause its increase. 

It must not be forgotten that in spite of every indication of ileus, 
i —mortem examination of the body sometimes fails to reveal any 
apparent cause of intestinal obstruction. Similar appearances some- 
times follow arsenical poisoning, and may be occasionally observed in 
cholera or in peritonitis. 

PROGNOSIS. Tie prognosis is always grave, yet not hopelc— 

Treatment. In all cases of simple intestinal constriction a liquid 
diet must be .prescribed, and the bowels should be kept open with laxa- 



DISEASES OF THE INTESTINES. 367 

tives or mineral waters. Obstructions which involve the pelvic organs 
can be frequently removed by appropriate surgical operations. When 
the symptom of complete occlusion arises, careful search should be 
made for the existence of hernial incarceration or strangulation ; 
especially should this be remembered in the case of women, who some- 
times present an unsuspected femoral hernia. Coprostasis should be 
treated by frequent flushing of the colon with warm water, and by the 
administration of the compound infusion of senna with Epsom salts or 
croton oil. In certain cases it becomes necessary to dig out the im- 
pacted feces from the rectum with the aid of a spoon before the tube 
of a syringe can be introduced. 

When the seat of obstruction cannot be reached through the rectum 
or the vagina, especially if torsion of the intestine be suspected, ab- 
dominal section should be undertaken. Many surgeons prefer the 
operation of enterotomy ; but in any case the knife should be used as 
early as possible, for the chances of recovery are rapidly diminished 
by delay. 

If surgical interference be out of the question, large doses of opium 
(half a grain every hour until the occurrence of pupillary contraction) 
must be employed, and purgatives must be positively forbidden. Some- 
times a favorable result has been attended by frequent irrigation of the 
stomach with the aid of the gastric syphon. The operation should be 
repeated three or four times a day, and, if unsuccessful as a means of 
cure, will nevertheless add greatly to the comfort of the patient by 
washing out the stomach and upper bowel. The lower bowel should 
be also washed out frequently with water, and be pumped full of air. 

Puncture of the distended loops of the intestine with a fine trocar 
has been often followed by great relief, and has sometimes resulted in 
cure. Occasionally faradization of the intestine has been followed by 
relief and cure ; one electrode should be placed in the rectum, while 
the other is moved about over the abdominal surface. In desperate 
cases recourse may be had to the administration of metallic mercury, 
which should be given in almost any quantity up to two pounds by 
weight. 

Haemorrhoids — Phlebectasia Haemorrhoidalis. 

Etiology. The causes of haemorrhoids may be purely local, as in 
cases of obstinate constipation, when the veins of the rectum are per- 
sistently compressed by fecal masses. In other cases catarrhal inflam- 
mation of the rectum is the occasion of haemorrhoids. Cancerous and 
other strictures of the rectum are also frequently accompanied by 
hemorrhoidal dilatation of the rectal veins. 

In certain instances diseases of the uterus, ovaries, or prostate gland, 
compress the hemorrhoidal veins and produce piles. The same event 
is very common during the course of pregnancy. In like manner the 
existence of obstruction in the portal circulation, or in the thoracic 
organs, may produce blood-stasis and hemorrhoidal distention in the 
rectum. 

The disease is very common among corpulent, plethoric people who 
eat and drink excessively, especially if, at the same time, they are 



368 DISEASES OF THE ALIMENTARY CANAL. 

accustomed to sedentary habits. For these reasons the disease is most 
commonly observed during the later period of active life, among men 
rather than among women. 

Pathological Anatomy. Haemorrhoids are either external or in- 
ternal. They are external, when located below the sphincter ani 
muscle ; internal, when situated above that muscle. In many cases 
the anus is surrounded by a ring of tumors which consist of dilated 
bloodvessels covered with a membranous investment. Sometimes the 
varicose veins are widely separated from one another, constituting 
tumors of variable size. Sometimes the dilated veins become obstructed 
by the formation of thrombi, which finally become organized and effect 
a cure of the disease. In certain instances calcification of a thrombus 
takes place. Frequently the submucous tissues of the rectum become 
thickened, and a chronic catarrhal discharge of slimy or muco-purulent 
liquid oozes from the mucous surface. Not unfrequently the connective 
tissue around the rectum becomes acutely inflamed, and abscesses form, 
which may rupture into the rectum, or externally, or in both directions, 
producing an internal, an external, or a complete rectal fistula. 

Symptoms. The existence of hcemorrhoids usually produces in the 
rectum a feeling of weight and pain, which is liable to be increased 
by over-eating, or by protracted sitting, or by excessive debauchery. 
The act of defecation is followed by great pain, which may result in 
faintness or convulsions. The dread of such pain leads to a long 
retention of the feces, and consequent general discomfort. In cer- 
tain cases the principal symptom is afforded by a chronic, slimy 
discharge from the rectum, which is often attended by tenesmus and 
frequent defecation, so that the disease may be mistaken for dysentery. 
In other cases copious hemorrhage takes place, which usually appears 
in the form of an oozing from the capillary vessels. Such a discharge 
of blood frequently affords great relief to the feelings of discomfort 
and universal disorder by which it has been preceded. The amount of 
discharge is rarely sufficient to produce any danger. When voided 
with the feces, the blood is not mixed with them, but lies upon the 
surface of the fecal cylinder, and presents very little change in color, 
since its source is so near the anus. 

Much more serious consequences follow the prolapse and strangula- 
tion of internal hemorrhoids. The varicose tumors descend through 
the sphincter ani muscle by which they are spasmodically grasped and 
strangulated. This condition is productive of intense suffering. The 
patient lies upon his side, with his knees drawn up against the belly, 
in order to avoid, if possible, any movement of the strangulated parts. 
If they cannot be replaced, they are liable to become gangrenous and 
to slough away, by which event a natural cure may be effected, though 
the process is attended with considerable danger of pyemia. 

The duration of the disease is liable to great variations. Slight 
attacks, dependent upon transient causes, are soon relieved, but many 
cases are of life-long duration. 

Diagnosis and Prognosis. Hemorrhoidal tumors are to be dis- 
tinguished from excessively developed cutaneous folds about the anus, 
which differ by the absence of the varicosity and blue color that marks 



DISEASES OF THE INTESTINES. 369 

the existence of venous dilatation. From condylomata they may be 
distinguished by the absence of other indications of syphilis, and from 
rectal cancer by the absence of cachexia, and by the distinctly venous 
constitution of the tumors. The prognosis is usually very favorable. 

Treatment. In the treatment of haemorrhoids prophylactic meas- 
ures are of great importance. The habits of life must be regulated, 
and all excess of diet and luxury must be restrained. Patients who 
are in the habit of consuming large quantities of meat, wine, and beer 
should exchange these articles for vegetables, fruits, and milk. Suf- 
ferers from chronic diseases of the liver or thoracic organs must be 
aided as far as possible to avoid the occurrence of blood-stasis. In all 
cases the bowels must be regularly relieved. For this purpose one or 
two teaspoonfuls of compound licorice powder may be taken every 
night. The old-fashioned confection of sulphur and cream of tartar is 
another very useful laxative. Mild forms of the disorder may be quite 
relieved by small doses, long continued, of sulphur and cream of tartar 
in the form of a tablet (1^. Lac. sulphur., gr. v, potass, bitart., gr. j, 
sacch., gr. x. M.). The water of the Karlsbad or Saratoga springs 
exercises a favorable effect upon the majority of patients who are 
plethoric and vigorous. Weakly and anaemic patients should make use 
of waters containing iron as well as sulphur. Change of air and occupa- 
tion are beneficial in cases of chronic constipation dependent upon a 
sedentary life. 

For the local relief of painful haemorrhoids, suppositories containing 
morphine and belladonna, with butter of cocoa, are useful ; also, the 
compound gall ointment, reinforced with cocaine (gr. x to the ounce), 
forms an excellent application to external haemorrhoidal tumors. The 
daily injection of cold water is frequently beneficial ; though many 
patients obtain greater relief from similar injections of hot water. 
Severe hemorrhage may be treated by astringent injections or supposi- 
tories, in the rectum. Applications of ice are usually sufficient to 
arrest any ordinary flow. If internal haemorrhoids are prolapsed, the 
patient should be placed in the knee-elbow position, with the shoulders 
considerably lower than the hips, when, with the oiled finger, the tumor 
can be usually replaced. If any difficulty attend this operation, ether 
should be administered, and forcible dilatation of the sphincter ani will 
greatly facilitate the reduction of the tumor. Great relief from pain 
and speedy recovery follow this method of treatment in the vast 
majority of cases. If neglected haemorrhoids have become gangrenous, 
their separation and discharge should be favored by the application of 
warm poultices and by the free use of disinfectants. 

Those patients who are subject to recurrent attacks of haemorrhoids 
may frequently avoid much suffering by the application of half a dozen 
leeches around the anus whenever an attack is imminent. 

For the radical cure of haemorrhoids, the internal administration of 
Fowler's solution of arsenic has been recommended. Local injection 
of each little hemorrhoidal tumor with carbolic acid and glycerin 
(three drops of a 2:1 solution) is often practised. By this method 
the disease may be temporarily cured, but relapses are almost inevi- 

24 



370 DISEASES OF THE ALIMENTARY CAXAL. 

table. Complete extirpation by surgical methods affords the most 
lasting result, though relapses are even then not uncommon. 

Intestinal Hemorrhage — Enterorrhagia. 

Etiology. Intestinal hemorrhage occurs either as a consequence 
of an abnormal condition of the intestinal contents, or by reason of 
local diseases of the walls of the canal, or as a result of general and 
infective diseases. 

Obstinate constipation frequently occasions hemorrhage by the accu- 
mulation of hardened masses of fecal matter in the intestinal canal. 
Foreign bodies and caustic poisons which have been swallowed may 
also irritate and lacerate the mucous membrane. Certain parasite s> 
e. g., Anchylostomum duodenale, Distomum haematobium, produce 
hemorrhage by their action upon the mucous membrane. 

Among the local diseases by which hemorrhage can be produced are 
ulcerations, traumatic injuries, severe inflammation, and neoplasms 
which involve the mucous membrane. Hemorrhage is a common 
symptom in the course of intestinal intussusception. It may be also 
produced by any cause which seriously impedes the portal circulation, 
and is, consequently, not uncommon in chronic diseases of the liver 
and intra- thoracic organs In certain instances hemorrhage is directly 
dependent upon vascular disease, e. g., amyloid degeneration, embolic 
obstruction, or aneurismal dilatation of the bloodvessels. 

Intestinal hemorrhage is frequently observed in the course of infec- 
tive diseases, especially those which, like typhoid fever, dysentery, and 
syphilis, are accompanied by intestinal ulceration. Malarial fever is 
sometimes accompanied by hemorrhage which is dependent upon 
obstruction of the hepatic vessels by the deposit of melanin. It fre- 
quently occurs in the course of other infective diseases, when hemor- 
rhagic conditions are developed. In like manner it is a common 
occurrence in scurvy, purpura, haemophilia, urcemta, and cholcemia. 

Pathological Anatomy. The whole length of the intestinal canal 
is sometimes occupied by dark clots of blood. In other cases the effused 
liquid exhibits a brownish, flocculent appearance like the grounds of 
beef-tea. In certain cases the clots are condensed and dried into hard 
and carbonaceous masses : in others the intestinal fluids resemble water 
in which raw meat has been washed, and contain flakes of mucus and 
pus. Sometimes ulcerated surfaces are visible upon which the source of 
hemorrhage can be distinguished. In other instances it is evident that 
capillary oozing has been the only source of the effusion. After repeated 
hemorrhages the other organs generally manifest the appearances of fatty 
degeneration, which is the direct consequence of an insufficient supply 
of oxygen through the blood. 

Symptoms. In certain cases intestinal hemorrhage is followed by 
rapid and complete collapse without the external appearance of any 
blood. This sometimes happens in cases of typhoid fever, which may 
thus result fatally in a very brief period of time. But the presence of 
blood in the stools is observed in the vast majority of cases. The 
nearer its source to the lower extremity of the bowels, the brighter the 



DISEASES OF THE INTESTINES. 371 

color of the blood. When it has been discharged into the upper por- 
tion of the intestines, the color is dark or completely black, and the 
odor may be very offensive. Hsematemesis occurs only when the seat 
of the hemorrhage is located in the duodenum. Sometimes, as in other 
cases of internal hemorrhage, the patient is conscious of a sensation of 
warmth and trickling, by which the locality of the hemorrhage is indi- 
cated. In severe or continuous cases the evidences of impoverishment 
of the blood are developed. The extremities become oedematous, and 
the urine exhibits traces of albuminuria, both of which are consequences 
of ansemia. 

Diagnosis. In certain cases of obstinate constipation, the feces 
present a dark color which may be mistaken for blood ; an excess of 
bile in the stools may produce a similar appearance. The juices of 
certain fruits, and medicinal substances, like hematoxylin, may discolor 
the stools ; the dark color which follows the use of iron and bismuth is 
produced by the formation of their metallic sulphides in the alimentary 
canal. By stirring the feces with water the liquid is stained with blood, 
if any be present ; in doubtful cases the aid of the microscope, or of the 
spectroscope, may be invoked. The previous history of the patient will 
readily determine the presence in the stools of blood which has been 
derived from the mouth, nose, oesophagus, respiratory passages, or 
stomach. Infants sometimes void blood which has been derived from a 
bleeding nipple, or from the maternal passages. The source of hemor- 
rhage can usually be easily discovered when the rectum or the lower 
part of the bowels is involved ; in such cases, the quality of the blood 
and its deposition upon normal fecal masses, indicate a source in the 
large intestine. Thin serous discharges that resemble the washings of 
raw meat occur in the course of dysentery. Black, tarry discharges 
may be referred to the duodenum, especially if they have been preceded 
by burns or scalds upon the external surface of the body. 

Prognosis. The prognosis is dependent upon the cause and amount 
of the hemorrhage. In certain cases it is not without benefit to the 
patient, as may be observed when a moderate hemorrhage occurs during 
the course of typhoid fever that is accompanied by high temperature 
and cerebral symptoms. 

Treatment. The general treatment must be based upon the pre- 
disposing causes of hemorrhage. Absolute rest in the horizontal posi- 
tion, and a light and cooling diet, must be prescribed. An ice-bag 
should be placed as near as possible to the seat of hemorrhage. Hypo- 
dermic injections of ergotine should be given, and five to ten drops of 
liquor ferri perchloridi may be taken, in water, every two hours. Ex- 
cessive movement of the bowels should be quieted by half-grain doses 
of opium, repeated every hour until pupillary contraction is apparent. 
Hemorrhage from the rectum and large intestine may be controlled by 
injections of cold water, to which astringents may be added. Malarial! 
hemorrhages require the administration of quinine in large doses (15 to 
30 grains). If the patient pass into a state of collapse, alcoholic stimu- 
lants and musk (4 grains every hour) must be given. Hypodermic in- 
jections of camphor (camphor, 3 grains, almond oil r half a drachm) may 



372 DISEASES OF THE ALIMENTARY CANAL. 

be administered three times a day. During convalescence, iron, arsenic, 
tonics, and good diet will be required. 

Melaena Neonatorum. 

The term mel^na is applied to those cases of newborn children which 
are characterized by vomiting and purging of blood, that is not the 
result of accidental swallowing of blood in the acts of birth or of nursing. 
Such hemorrhage may be sometimes traced to definite causes of a trau- 
matic character, or may be dependent upon an unhealthy condition of 
the mother, by which the nutrition of the foetus was impaired. Local, 
vascular changes connected with cicatrization of the umbilicus are some- 
times assigned as the cause of hemorrhage. In other cases it is thought 
to be the consequence of puerperal infection from the mother ; while, in 
manv cases, no special cause can be discovered. The occurrence of 
hemorrhage is usually observed before the third day of infantile life. 
Collapse and a fatal termination may speedily follow ; and, in cases of 
recovery, the evidences of debility are sometimes of life-long duration. 
A fatal result is witnessed in about one-half of the cases. The treat- 
ment must be conducted in accordance with the rules laid down for the 
management of intestinal hemorrhage, having due regard to the age of 
the patient. At the time of delivery the umbilical cord should not be 
divided before it has ceased to pulsate. If the mother be attacked by 
puerperal fever, the infant should be removed, for fear of infection. 

Colic — Enteralgia. 

Colic is a term applied to all cases of intestinal pain which occur 
independently of any anatomical change in the alimentary canal. It 
may be produced by coprostasis, by foreign bodies, parasites, gall- 
stones, or by undigested and fermenting food Certain persons always 
experience an attack of colic after the ingestion of particular articles of 
diet. Fermenting substances, which liberate large quantities of gas 
within the intestines, are very common causes of pain. The effects of 
lead and copper, and the irritating quality of many purgative remedies are 
well known. Certain nervous diseases, such as hypochondria, hysteria, 
neurasthenia, and tabes dorsalis are not unfrequently attended by par- 
oxysms of severe colic. It is also often associated with diseases of the 
abdomen and pelvic organs. It is, moreover, a common consequence 
of exposure to malaria, or to sudden cold when overheated, especially 
among arthritic patients. 

Symptoms. The prominent symptom is pain, of a griping and spas- 
modic character, which is referred particularly to the region of the navel, 
whence it radiates in every direction. It may be accompanied by gur- 
gling in the bowels, which are frequently distended and prominent. 
The pain is. frequently, remittent and paroxysmal, and may be. in 
many cases, quite intolerable. It is often diminished by pressure, so 
that the patient instinctively compresses the belly with his hands or 
throws himself upon his face over a hard pillow. In other cases, how- 
ever, a concurrent cutaneous neuralgia renders the abdomen tender 



DISEASES OF THE INTESTINES. 373 

and painful on pressure. Fever, however, is absent. In many cases 
the paroxysm subsides rapidly after the evacuation of gas, or after a 
movement of the bowels. Death rarely occurs, though it has been ob- 
served in connection with rupture of the intestines, or as a consequence 
of convulsions excited by the severity of the pain. 

Diagnosis and Prognosis. The differential diagnosis lies between 
colic and (1) Rheumatism of the abdominal muscles, an affection which 
continues longer, is more variable in its seat, and lacks the paroxysmal 
character of colic. (2) Lumbo- abdominal neuralgia, which is indi- 
cated by its limitation to the branches of the lumbo-abdominal nerves, 
and by the presence of characteristic points of tenderness. (3) Cuta- 
neous or muscular pain of a nervous character, which is distinguished 
by its rapid disappearance on the application of Faradic electricity. 
(4) Circumscribed peritonitis, in which fever and dulness on percussion 
are prominent symptoms. 

The prognosis is almost always favorable, though somewhat dependent 
upon the habits of the patient. 

Treatment. Speedy relief from pain may be obtained by the hypo- 
dermic injection of morphine and atropine, or by the internal adminis- 
tration of twenty to thirty grains of chloral hydrate or opium in half- 
grain doses every hour until pupillary contraction is observed. The 
abdomen should be covered with a large warm poultice that has been 
sprinkled with a drachm of chloroform. Mild cases may be relieved by 
fifteen to twenty drops of chlorodyne, or by teaspoonful doses of the 
camphorated tincture of opium, given with a few drops of the tincture 
of the oil of peppermint, in a wineglass of hot water. Frequent recur- 
rence of the paroxysms requires careful regulation of the diet, and 
proper clothing, to avoid chill. Electricity is sometimes beneficial as a 
local counter-irritant and tonic. 



PART IT. 

DISEASES OF THE LIVER, PANCREAS, 
PERITONEUM, AND SPLEEN. 



CHAPTEE I. 

DISEASES OF THE LIVER. 

Constriction and Occlusion of the Biliary Passages — Icterus. 

Etiology. The only symptom by which constriction of the biliary 
passages can be recognized is the occurrence of jaundice. Since the 
pressure within the biliary canals is very low, slight obstructions are 
sufficient to produce stagnation of the bile and its resorption through 
the lymph ducts and capillary vessels into the general circulation of the 
body. The seat of obstruction may be located either in the biliary 
capillaries themselves, or in the large bile ducts outside of the liver. 

Jaundice may accompany any disease of the liver that is not attended 
by destruction of the secretory cells of the organ, yet it may be some- 
times absent and sometimes present in the course of the same disease ; 
a circumstance which is dependent upon the condition of the biliary 
passages. It may also result from enlargement of the periportal lymph 
glands, or as a consequence of cancerous nodules by which the hepatic 
duct or the common bile-duct are compressed. An inflammatory con- 
dition of those ducts, or the obstruction of their common orifice by 
catarrhal swelling of the duodenal mucous membrane, may occasion 
stagnation of bile and jaundice. In like manner the intrusion of 
foreign bodies, such as gall-stones, or the seeds of fruit, or intestinal 
parasites, may produce obstruction. The same thing has been observed 
as a consequence of cicatricial constriction and the development of neo- 
plasms and malignant growths that encroach upon the biliary passages. 
Chronic peritonitis may constrict the passages ; and their congenital 
occlusion by intra-uterine inflammation has also been known to occur. 

Intra-thoracic diseases that interfere with the movement of the 
diaphragm may sometimes favor the stagnation of bile within the 
liver, since its evacuation is greatly aided by the pressure to which the 
organ is subjected during the movements of respiration. In certain 
cases an occlusion of the portal vein may lead to jaundice, through a 
reduction of pressure within the branches of the vein to a point below 
the tension of the bile in the biliary passages. Under such circum- 



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of die cystic dnct: nndervhich circmnstances th 
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it 




DISEASES OF THE LIVER. 377 

calculi. Recovery is preceded by the gradual reappearance of a biliary 
color in the feces, and by its disappearance from the skin. The urine 
gradually loses its dark color, and finally the skin by degrees resumes 
its normal hue. 

During the course of jaundice the patient is often tormented by 
itching in the skin ; the irritation is frequently universal, though it 
may be particularly annoying in the palms of the hands, the soles of 
the feet, and between the fingers and toes. Its cause lies in a peculiar 
excitation of the cutaneous nerves by the acids and pigment of the 
bile. 

Erythematous and urticarious eruptions sometimes appear upon the 
surface of the body. The perspiration, and among nursing women the 
milk, is charged with these substances ; occasionally during pregnancy 
the foetus becomes jaundiced. Under such circumstances the death of 
the newborn infant is a common event, and the mother incurs the risk 
of acute yellow atrophy of the liver. 

In certain cases xanthopsia, or colored vision, occurs during the 
course of jaundice; this rare event is supposed to be dependent not 
upon the discoloration of the optic media with biliary pigment, but 
upon the condition of the central nervous organs, since the symptom is 
frequently intermittent, and does not coincide with the intensity of the 
jaundice. 

The movements of the heart are frequently retarded, even during 
the course of fever from any cause. The patient becomes sleepless, 
emaciated, debilitated, and despondent. Death may occur as a conse- 
quence of progressive exhaustion, dropsy, hemorrhage, and diarrhoea. 
In certain cases the phenomena of cholcemia are developed ; the patient 
becomes delirious, restless, and unconscious ; respiration is irregular ; 
copious hemorrhage occurs from the mucous membranes and beneath 
the skin ; involuntary evacuations occur, and death concludes the 
scene. This fatal result has been attributed by some to the action of 
the biliary acids ; by others it is referred to cholesterine poisoning. 
In certain cases death has been observed as a result of the rupture of 
the gall bladder or distended biliary passages, followed by peritonitis. 
Rupture within the liver produces the phenomena of hepatic abscess. 

Pathological Anatomy. The most conspicuous appearance after 
death is derived from the general pigmentation of the tissues. The 
biliary passages and the gall bladder are usually dilated and distended 
with liquid ; their walls are sometimes thickened, or they may be ex- 
traordinarily thinned. The liver is enlarged, or, if the disease has 
continued for a considerable period of time, it is contracted and firm. 
In early cases its color is yellow, but at a later period it exhibits a 
green or dark color. The central veins in the lobules are surrounded 
by a zone of deeper color. The kidneys present a greenish hue, and, 
on section, recent cases appear of a saflfron-yellow color. The con- 
sistence of the organ is flaccid and soft. The epithelial cells in the 
uriniferous ducts are stained with pigment, and the passages them- 
selves are frequently obstructed with pigment and cylindrical casts 

Diagnosis. Jaundice can be easily recognized by daylight, though 
not by artificial illumination. It may be distinguished from the hue of 



378 DISEASES OF THE LIVER, ETC. 

anaemia and from the cutaneous discoloration which accompanies 
Addison s disease or cachectic conditions, by the fact that in all such 
disorders the sclerotic coat of the eye remains white and unstained by 
the bile pigment that is so conspicuous in jaundice. The characteristic 
condition of the urine and of the feces also serves to complete the 
diagnosis. 

Prognosis. The prognosis is dependent upon the cause of the 
disease. It is favorable in catarrhal cases, but when appearances of 
dissolution of the blood or the symptoms of chohemia are present. 
the prognosis is exceedingly unfavorable. 

Treatment. A liquid diet, from which oils and fats have been as 
far as possible removed, must be recommended. An abundance of 
water, lemonade, or other agreeable drinks, may be allowed. The bitter 
taste and offensive condition of the mouth may be relieved by the min- 
eral acids, which must be given in perfect dilution with a large quantity 
of water. Constipation may be relieved by the use of vegetable laxa- 
tives, such as rhubarb, the compound infusion of senna, compound 
licorice powder, and pills of aloes and rhubarb. Mercurials are un- 
necessary. The urine should be carefully collected and measured ; if 
deficient in quantity, diuretics must be prescribed ; of these the citrate 
of potassium is to be preferred (R. Potass, citrat., 51J ; aqua?, Oj. S. : A 
tablespoonful in a wineglassful of water, every two hours). Cutaneous 
irritation may be relieved by the use of bromide of potassium (half a 
drachm of the salt, every morning and evening) Warm baths in 
which a handful of soda has been dissolved are also a source of great 
comfort. Insomnia may be relieved by thirty-grain doses of chloral 
hydrate at bedtime or by the use of the same quantity of sulfonal. 
Choltemia must be combated by stimulants and camphor internally or 
by hypodermic injections. Mustard poultices may be applied to the 
back of the neck ; ice-bags to the head, and cups along the spine. 

Catarrhal Jaundice — Cholangitis et Cholecystitis Catarrhalis. 

Etiology. Catarrhal jaundice rarely occurs as a primary conse- 
quence of exposure to cold. It is generally produced by a catarrhal 
inflammation of the stomach and duodenum which has invaded the 
common bile-duct ; though it may be excited by the presence of para- 
sites or calculi or foreign bodies in the biliary passages. It is some- 
times observed in connection with diseases of the hepatic tissue or as a 
consequence of blood-stasis dependent upon intra-thoracic diseases. 
It is sometimes connected with menstrual disturbances which produce 
vicarious hyperemia of the liver. It may result from cerebral and 
nervous disturbances which produce derangements in the hepatic circu- 
lation. In certain cases it is produced by the action of lead or phos- 
phorus, or after the excessive use of chloral hydrate. In like manner 
it may result from the causes of infective diseases. The concomitant 
action of cold, malaria, and impure water is a frequent cause of the 
disease. 

Symptom.-. The symptoms of catarrhal jaundice do not differ from 
those which have already been described in connection with obstructive 



DISEASES OF THE LIVER. 379 

jaundice. The duration of the disease varies from two to six weeks, 
though it may occasionally continue for a longer period of time ; but,' 
in such cases, the suspicion of a more serious cause than catarrhal 
inflammation must be entertained. In cases that are characterized by 
adhesive inflammation the biliary passages may become permanently 
occluded, and chronic jaundice is the result. 

Pathological Anatomy. An opportunity for observing the con- 
sequences of catarrhal jaundice is rarely furnished, since the disease 
generally terminates in recovery. It is evident, however, that the bile- 
ducts are obstructed by the swelling of their walls and by the accumu- 
lation of exfoliated epithelium and mucus. The passages, above the 
point of constriction, become dilated ; their cells are thickened ; some- 
times calcification takes place ; and, if the cystic duct be obliterated, 
dropsy of the gall bladder is produced. The hepatic tissue is deeply 
tinged with bile pigment. 

Diagnosis and Prognosis. The recognition of catarrhal jaundice 
is generally easy, though it may be confounded with jaundice from 
impaction of gall-stones in the biliary passages. Under such circum- 
stances, however, colic is experienced, and the jaundice is of shorter 
duration than when it depends upon simple catarrhal causes. 

The prognosis is almost always favorable. 

Treatment. The particular indication for treatment points to the 
removal of catarrhal inflammation. The patient should be restricted 
to a liquid diet, and may be treated by the administration of dilute 
mineral acids, either hydrochloric acid or nitro-muriatic acid, of which 
five drops may be given in a large glass of water every three or four 
hours. Lemonade may be allowed in unlimited quantities. Copious 
irrigation of the colon with water, which should be retained as long as 
possible, affords an excellent result. Sometimes, faradization of the 
hepatic region, or gentle compression of the gall bladder, causes the 
expulsion of obstructions from the biliary passages, with consequent 
relief of all symptoms. The same result sometimes follows the use of 
moderately cathartic doses of podophyllin, which provoke an active 
peristalsis in the common bile-duct. 

Suppuration of the Gall Bladder — Empyema Cystidis Felleae. 

The mucous membrane of the biliary passages of the gall bladder 
sometimes undergoes suppurative inflammation. This frequently results 
from the mechanical irritation that is produced by gall-stones, or para- 
sites, or other foreign bodies. The obliteration of the cystic duct which 
may be thus produced is followed by an accumulation of pus in the 
gall bladder, which sometimes becomes greatly distended. The physi- 
cal signs are those which might be expected from the presence of a 
rounded or oval sac beneath the liver, near the outer border of the right 
rectus muscle. Resorptive fever of a hectic character is frequently 
observed. The prognosis is grave, and the treatment requires surgical 
intervention. 



380 DISEASES OF THE LIVER. ETC. 



Dropsy of the Gall Bladder — Hydrops Cystidis Felleae. 

Etiology. Dropsy of the gall bladder consists in the replacement 
of its normal contents by a mucous or serous liquid. It generally 
results from occlusion of the neck of the gall bladder, or of the cystic- 
duct, by adhesions, or by the incarceration of gall-stones. The biliary 
contents of the gall bladder are then gradually removed by absorption, 
and the cavity is distended with a mucous or serous fluid that oozes 
from the walls of the cyst. In certain instances the gall bladder has 
been thus distended until its contents reached a weight of sixty or 
eighty pounds. The cystic wall becomes gradually atrophied, and the 
glandular structures of its mucous membrane disappear. 

Symptoms. The distended gall bladder may be recognized as a 
smooth and sometimes fluctuating tumor which moves with the liver, in 
unison with the respiratory action of the diaphragm. In the majority 
of cases no serious discomfort is experienced unless the tumor has 
reached an inconvenient size. 

Diagnosis. Cystic dropsy may sometimes reach such magnitude as 
to be mistaken for ascites. It may be distinguished from empyema of the 
gall bladder by the absence of fever and cachexia ; from cancer of the 
gall bladder by its rounded and regular form, which differs from the 
firm and nodulated tumors of cancer ; from gall-stones by a sensation 
of fluctuation or bladder-like tension instead of the stony hardness that 
is presented by an accumulation of calculi ; from excessive accumula- 
tions of bile by the absence of jaundice, and by the greater duration of 
the disease ; from echinococci by the absence of hydatid fremitus, and 
by the pedunculated character of the tumor; from hepatic abscess by 
the absence of fever and chills : from hydronephrosis by its movement 
in unison with the respiratory action of the diaphragm ; from ovarian 
tumors by their similar independence of respiratory movement, and 
their development from below upward. 

Prognosis. The prognosis is generally favorable. Rupture rarely 
occurs unless from external violence. 

Treatment. The treatment must necessarily be of a surgical char- 
acter. The preference is usually given to cholecystectomy, since 
cholecystotomy is liable to be followed by a reproduction of the disease. 



Cancer of the Biliary Passages. 

Secondary cancerous growths sometimes invade the biliary passages 
from the neighboring organs, or occur by metastasis from distant struc- 
tures. Primary cancer is a rare disease, and more frequently attacks 
the gall bladder than the biliary ducts. It produces a nodulated tumor 
which may attain to great size, and is accompanied by pain, jaundice, 
vomiting, bloody diarrhoea, and death by exhaustion. Sometimes the 
gall bladder is found distended with bile, or with gall-stones and broken- 
down cancerous masses, which may. by ulceration, effect a communica- 
tion between the cavity and the peritoneal sac or the neighboring 
intestines. 



DISEASES OF THE LIVER. 381 

Other non-malignant tumors are occasionally described in connection 
with the biliary passages. 

Biliary Calculi — Gall-stones — Cholelithiasis. 

Etiology. Biliary calculi are most frequently observed among 
women after the fortieth year of life. Many writers are of the opinion 
that this greater proclivity on the part of the female sex is due to the 
intimate connection between the circulation of blood in the generative 
apparatus and in the liver. Sedentary habits, luxurious life, and 
intemperance in eating and drinking are frequent causes of the disease. 
In many instances the presence of foreign bodies such as parasites, 
clots of blood, and calcified masses which have found their way into the 
biliary passages, may serve as nuclei for the formation of calculous 
deposits. They are not unfrequently discovered in connection with 
atheromatous changes in the arteries, and with cancerous disease of the 
liver and stomach. 

Pathological Anatomy. Biliary calculi may be developed or 
formed in any portion of the biliary passages. They are most fre- 
quently found in the gall bladder. They vary in size from the most 
minute particles to masses that fill the entire cavity of the gall bladder, 
and their number is proportionately variable, being sometimes counted 
by the thousand. Their form varies according to the location of the 
calculi ; in the biliary passages they exist as cylindrical masses that are 
moulded by the walls of the ducts in which they lie; within the gall 
bladder they present an irregularly oval outline, frequently resembling 
that of a nutmeg; in other instances they possess a more or less poly- 
hedral shape, with opposing facets of an irregularly crystalline form ; 
in this way a cluster of gall-stones is sometimes formed that recalls the 
mode of articulation among the small bones of the wrist. The surfaces 
of the calculi are usually smooth and slippery, but sometimes they are 
nodulated or mulberry-like. The color varies from light-gray to brown, 
dark-green, or black, according to the difference of chemical constitu- 
tion. Calculi that are composed of cholesterine are of a light color. 
The more pigment they contain the darker the tint. 

Moist gall-stones can be easily crushed, and they impart a greasy 
sensation to the fingers. Sometimes they are composed of concentric 
layers; occasionally a foreign body can be found near the centre where 
it has formed a nucleus for the deposit of calculous matter. The weight 
of gall-stones depends upon their chemical constitution; cholesterine 
calculi, however bulky, are of light weight, and when thoroughlv dried 
may float in water. 

The chemical constitution of biliary calculi differs considerably ; in 
the majority of instances they are composed of pure cholesterine, and 
it is a rare thing to find that substance entirely absent in any case. 
Calculi that are composed of simple pigment are colored either brown, 
or green, or black. Calculi composed of calcium carbonate are occa- 
sionally discovered ; they may be recognized by their light color and 
their extreme hardness and weight. The most common variety of gall- 
stone contains both cholesterine and pigment. 



382 DISEASES OF THE LIVER, ETC. 

The presence of gall-stones very commonly serves to excite irritation 
and inflammation in the gall bladder and biliary passages ; conse- 
quently, all the processes and products of inflammation may be there 
exhibited. 

The proximate causes of calculous formation are not sufficiently known : 
it is probable that inflammatory conditions which occasion an excessive 
secretion of mucus may exert a modifying influence upon the structure 
of the biliary acids by which cholesterine and pigment are held in solu- 
tion ; catarrhal changes in the mucous membrane might then lead to a 
deposit of calculous matter. In the tissues cholesterine is held in solu- 
tion by lecithine, while in the bile a similar condition of solubility is 
maintained by the biliary salts so long as the bile remains alkaline. 
When organic acids are redundant in fluids that contain cholesterine, 
calcic bases are dissolved out of the tissues, and are combined with the 
fatty acids and biliary acids of the bile, forming insoluble soaps and 
cholates. Cholesterine can no longer remain in solution, and is precipi- 
tated A similar result occurs in stagnant and concentrated bile, especi- 
ally if the alkalinity of that fluid be reduced. Now all these morbid 
conditions are united when acid dyspepsia and a sedentary life concur 
to hinder the normal process of oxidation in the tissues. For this 
reason the arthritic diathesis is a potent predisposing cause of the disease. 

Symptoms. The existence of biliary calculi remains often unsuspected 
throughout the whole course of life ; in other cases the distended gall 
bladder and the nature of its contents can be readily distinguished be- 
neath the margin of the liver ; yet no inconvenience will be experienced 
unless liberation of a calculus takes place. In spite of various minor 
disturbances which cannot be positively referred to the biliary ducts 
and gall bladder, the existence of calculi cannot be positively affirmed 
unless the symptoms of biliary colic are experienced. Sometimes the 
paroxysm commences spontaneously, without any previous warning ; in 
other instances it may have been preceded by violent exercise, or by 
agitation of a nervous character. The onset of the paroxysm generally 
follows some unusual indulgence in the pleasures of the table. 

Biliary colic is characterized by intense pain of a boring, burning, 
or lancinating character, that is referred to the right hypochondriac 
region, but also radiates upward and downward along the entire right 
side of the body and into the limbs. The countenance expresses intense 
agony ; the abdominal wall, especially upon the right side, is tense and 
rigid ; pressure usually occasions an increase of pain ; the paroxysm is 
almost always introduced by a chill; sometimes the temperature rises, 
but it frequently remains normal, or even subnormal. The pulse is 
subject to considerable variation, and respiration is intermittent and 
attended with difficulty ; vomiting frequently occurs, and is sometimes 
associated with hiccough ; the bowels are generally confined, though 
sometimes diarrhoea occurs ; the urine is scanty, and loaded with urates ; 
sometimes delirium and hystero- epileptic convulsions are exhibited by 
nervous patients; convulsions and unconsciousness may occur, even 
among previously healthy individuals. 

The paroxysm usually continues for several hours ; sometimes it 
ceases suddenly, but it often subsides gradually. 



DISEASES OF THE LIVER. 38$ 

The occurrence of biliary colic is due to irritation of the biliary ducts 
by a calculus which has become engaged in the passage. Obviously, 
the larger and the rougher the stone, the greater the amount of suffer- 
ing which must continue until the passage has been cleared, either by 
the escape of the stone, or by its relapse into the gall bladder. If the 
calculus becomes impacted in one of the ducts, acute pain may gradu- 
ally subside and give place to the symptoms of permanent obstruction. 
If the cystic duct be thus occluded, jaundice will not necessarily follow; 
but when the hepatic duct, or the common bile-duct, is occupied by a 
calculus, jaundice generally appears in the course of three days. He- 
patic abscess or cancerous disease may sometimes occur as a sequel of 
the impaction. 

A fatal termination rarely follows biliary calculi. Recovery is the 
rule, though relapses are very frequent. After a paroxysm, examina- 
tion of the stools during the period of a week will sometimes be rewarded 
by the discovery of calculi. The feces should be thoroughly mixed with 
water, and strained through a coarse sieve ; but a failure to detect any- 
thing is exceedingly common. When biliary calculi have become im- 
pacted in the bile-ducts very serious consequences may be sometimes 
developed. The wall of the duct may become ulcerated and perforated, 
leading to the discharge of calculi into the peritoneum, and to the 
establishment of either encysted or general peritonitis. In other cases 
the process of ulceration may be attended by adhesions, and by the 
formation of fistulous communications with the stomach, intestines, 
urinary passages, or even with the intra-thoracic cavities and the air- 
passages. If such grave processes of ulceration and perforation do not 
take place, the phenomena of obstruction may be exhibited in the terri- 
tory of the liver, which becomes enlarged, or, finally, contracted, lead- 
ing to death from chohemia. Jaundice or dropsy of the gall-bladder 
may be manifested as minor consequences of obstruction. 

In certain cases the presence of gall-stones may occasion inflamma- 
tion and adhesion between the anterior surface of the gall bladder and 
the abdominal wall, followed by perforation and the establishment of a 
biliary fistula through which calculi and bile are discharged externally. 
Perforation is preceded by the symptoms of abscess at some point in 
the abdominal wall. The process may occur in cases where, by reason 
of the absence of all symptoms, the previous existence of biliary calculi 
had never been suspected. 

The discharge of biliary calculi into the intestine is not always fol- 
lowed by relief from danger. Obstruction of the intestines by large 
gall-stones, or by concretions for which they have furnished the nuclei, 
have been known to occur. In certain cases typhlitis or its allied dis- 
eases have been observed, in consequence of irritation of the caecum and 
vermiform appendix by calculi from the liver. 

Diagnosis. The diseases with which biliary calculi may be con- 
founded are quite numerous. 1. G-astralgia generally follows a meal, 
is accompanied by symptoms of gastric disorder, is located in the region 
of the stomach, and is not followed by jaundice. 2. Colic. Flatulence 
and pain are generally diminished by pressure; and when caused by 
lead poisoning, other symptoms of that disease are exhibited. 3. Hepatic 



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sanaL 



DISEASES OF THE HEPATIC PARENCHYMA. 385 

If frequently recurrent attacks of biliary colic admit of no permanent 
relief by medicine, surgical aid must be invoked. The operation of 
cholecystectomy affords the most radical cure, though the establishment 
of an artificial passage between the gall bladder and the intestine has 
been recommended. 



CHAPTEK IT. 

DISEASES OF THE HEPATIC PARENCHYMA. 

Venous Congestion of the Liver — Hyperemia Hepatis Venosa. 

Etiology. Passive congestion of the liver may be produced by any 
cause that hinders the onward passage of the blood from that organ to 
the heart. It is generally observed as a consequence of disease involv- 
ing the intra-thoracic organs, or producing compression of the inferior 
vena cava or of the hepatic veins below the diaphragm. 

Pathological Anatomy. Passive hyperemia of the liver is indi- 
cated by an increase in its volume and in the amount of blood which it 
contains. The peritoneal surface appears tense, smooth, and sometimes 
considerably thickenpd. On section of the organ, the central veins of 
the lobules appear distended, and are surrounded by a zone of darkly 
pigmented cells which contrast strongly with the paler border of the 
acinus. In chronic cases the liver undergoes irregular contraction, pro- 
ducing an uneven and nodulated appearance of its external surface, 
while its substance exhibits greater density than in the natural condi- 
tion. This condition is produced by the proliferation and contraction 
of the interlobular connective tissue. By the pressure thus exercised, 
and by the pressure of the dilated intra-lobular capillaries, the hepatic 
cells are compelled to undergo fatty degeneration and atrophy. This 
condition may be distinguished from the appearances that are presented 
in cirrhosis of the liver, by the fact that the hypersemic liver exhibits a 
darker color, is less uniformly contracted, and is not accompanied by 
chronic enlargement of the spleen. 

The whole territory of the portal circulation exhibits the phenomena 
of blood stasis; the gastric and intestinal capillary vessels are distended ; 
and the mucous surfaces of the alimentary canal exhibit the evidences 
of catarrhal inflammation. Hemorrhoidal dilatation of the rectal veins 
is a common occurrence. The kidneys and other abdominal and pelvic 
organs show the signs of hyperemia in consequence of their dependence 
upon the condition of the inferior vena cava. 

Symptoms, Diagnosis, and Prognosis. The most prominent 
symptom of passive hepatic congestion is furnished by the enlargement 
of the liver. The right hypochondrium is evidently distended ; the 
upper border of hepatic dulness extends above its normal level at the 
inferior margin of the sixth rib, while the inferior border of the organ 

25 



386 DISEASES OE THE LIVER, ETC. 

descends below the middle point between the ensiform process and the 
navel. These signs may be obscured by the presence of abdominal 
syi after the removal of the fluid the limits of the liver can be 
readily determined. In recent cases rapid variation in the dimeii- 
of the organ is often observed. Jaundiee is frequently present. The 
concurrence of heart disease under such circumstances produces a very 
peculiar combination of cyanotic and icteric tints. The general symp- 
toms )i r ■ " r" d catarrh are usually present, and all the other 
svmptoms of obstruction in the course of the circulation may be devel- 
oped. The occurrence of ; tet is especially connected with obstruc- 
tion in the course of the portal circulation, and it is usually developed 
as a consequence of hepatic atrophy. 

S\ ztioe symptoms are generally limited to a sensation of pressure 
and tension in the hepatic region, which is increased by the erect | - - 
tion. It is frequently impossible to lie upon the left side, and pain is 
often experienced through the right shoulder and in the right arm. A 
certain amount of difficulty is sometimes experienced in respiration by 
reason of interference with the movements of the diaphragm. D 
rarelv occurs from the hepatic disorder, but is usually 
the underlying causes of blood stasis. 

Treatment. The diet must be wholesome and nutritious, including 
a verv moderate allowance of fat. starch, and sugar. Half a dozen 
leeches may be applied to the anus, in order to unload the portal ves- 
sels, and the frequent application of cups or leech - the region of 
the liver affords a certain amount of relief. Cardiac disease, upon 
which passive hyperemia so often depends, requires the aid of digitalis 
or its substitutes. The vegetable L. should be employed for the 
purpose of relieving the bowels and aiding the hepatic circular. 

R . — Infus. rad. rhei. a tablespoonful three or four times a day. 
R . — Infus. sennte comp.. a tablespoonful three or four times a day. 
R — Pil. rhei comp.. two or three pills at bedtime- 

Vigorous patients may employ the strong cathartic mineral waters 
with advantage. Ascites frequently requires puncture of the peril 
cavitv. Diuretics are sometimes useful, but diaphoretics should be 
avoided on account of their debilitating effect upon the function of 

respirat: 

Acute Congestion of the Liver — Hyperaemia Hepatis Acuta. 

Acuii \ \a of the Uoer consists in an increased afflux of blood 

[f _ -rally accompanies an increase of activity in the 
portal circulation. This form of hyperaemia is a physiological pi 
during the course of digestion. It ma; pathological event 

when ssea the table and deficient exercise __ ate a 

normal function. 

Hyperemia frequently occurs as a consequence of s : the 

. and may lead to inflammation and ftbfi bs. It is n<«t uncommon 
as a local concomitant of h Useasei which d< ithin the sub- 

stance of the liver, and it is often observed in connection with 



DISEASES OF THE HEPATIC PARENCHYMA. 387 

diseases, especially in malarial fever. Its concurrence with menstrua- 
tion and as a consequence of menstrual suppression is not unusual, and 
it may result from the suppression of an habitual hcemorrhoidal flux. 
Certain well-known physiological experiments upon animals indicate a 
close connection between injuries or disturbances of the nervous system 
and the hepatic circulation, and may serve to explain the intimate 
relation between psychical and cerebral agitation and the states of the 
liver. 

Symptoms, Diagnosis, and Prognosis. The symptoms and diag- 
nosis vary in no essential particular from those which accompany 
passive congestion of the liver. The prognosis is generally favorable. 

Treatment. Hyperemia that is produced by injuries may be re- 
lieved by cold applications over the liver ; by the application of leeches 
to the anus ; and by repeated cupping of the hepatic region ; together 
with the use of vegetable laxatives. Malarial causes must be annulled 
by the use of quinine and arsenic. Menstrual obstructions may be 
obviated by the application of leeches to the inner sides of the thighs 
and by the use of hot foot-baths. 

Perihepatitis. 

Primary hepatitis is generally the result of injuries. The disease 
may also occur as a secondary consequence of diseases involving the 
liver itself or the stomach, intestinal canal, and kidneys. It some- 
times accompanies right-sided pleurisy, and in many instances it is a 
consequence of syphilis. 

Pathological Anatomy. Perihepatitis may be either circum- 
scribed or diffused, acute or chronic. Acute hepatitis presents the 
characteristic appearances of acute peritonitis involving the serous in- 
vestment of the liver. Sometimes abscesses form beneath the peritoneal 
membrane or penetrate the connective tissue of the liver. 

Chronic perihepatitis produces condensation of the hepatic perito- 
neum and frequently is accompanied by the formation of adhesions 
between the liver and neighboring structures. Contraction of the in- 
flamed capsule sometimes produces slight superficial depressions upon 
the external surface of the liver, and it may occasion a certain amount 
of constriction in the vessels at the hilum of the organ. The liver may 
also become diminished in size for the same reason. 

Symptoms, Diagnosis, and Prognosis. Perihepatitis is some- 
times unsuspected during life. In acute cases the disease is ushered 
in by a chill and fever, accompanied by pain in the region of the liver 
that is increased by pressure or any movement which involves the 
organ. Slight jaundice may occur as a consequence of impediments 
in the way of the respiratory movement. Loss of appetite, vomiting, 
and digestive disorders are frequent. Chronic perihepatitis is usually 
accompanied by friction sounds which accompany the movements of 
respiration, and are produced between the upper hepatic surface and 
the inferior surface of the diaphragm ; they are audible over the lower 
ribs upon the right side. Chronic jaundice and other symptoms of 



388 DISEASES OF THE LIVER, ETC. 

interference with the portal circulation are frequently observed. The 
prognosis is generally favorable. 

Treatment. Acute perihepatitis requires the application of warm 
poultices over the region of the liver, and the relief of pain by the 
hypodermic use of morphine and atropine. Cups, blisters, tincture of 
iodine, and mercurial ointment may be applied externally. Calomel 
may be given occasionally to aid the action of laxative remedies. The 
chronic form of the disease requires the treatment of such intercurrent 
disorders as may accompany its course. Long-continued external 
counter-irritation with blisters or cups is of considerable service. 

Abscess of the Liver — Hepatitis Suppurativa. 

Etiology. Abscess of the liver is more frequently observed in 
tropical climates, among the immigrants from the temperate zone, who 
do not conform to the customs and diet of the people with whom they 
are thrown, but who continue their alcoholic excesses under a southern 
sun. The disease occurs more often among men than among women. 
It is sometimes observed as a consequence of injuries, and in the 
majority of cases it is excited by the migration of pyogenic bacteria 
into the liver through the bloodvessels which communicate with that 
organ. In this way it may result from diseases or injuries of any of 
the abdominal or pelvic organs. It may occur as a consequence of 
septic infection through the umbilicus in newborn children. Thoracic 
diseases and peripheral inflammations may in like manner originate 
the disease, and it is a rather frequent consequence of osseous in- 
flammation, especially when the spongy portion of the bones is involved 
in the inflammatory process. 

Local diseases of the liver itself or of its biliary jjassages may serve 
as the starting-point from which hepatic abscess originates. In like 
manner tumors involving the neighboring organs mav also extend to the 
liver and be accompanied by suppurative processes. But, in spite of 
the severest scrutiny, it is sometimes impossible to discover any appar- 
ent cause for the formation of abscess in the liver. It is possible that 
in some of these instances the disease may depend upon the migration 
of parasites out of the intestinal canal into the liver. This has been 
observed in the endemic diarrhoea or dysentery of the tropics that is 
excited by parasitic amoebae. 

Pathological Anatomy. Abscesses of the liver may occur in any 
portion of the organ, but are much more frequently observed in the 
right lobe than in the left; they may be either single or multiple; 
their size varies from the most microscopical collection of pus corpuscles 
to a cavity as large as a cocoanut. The purulent contents generally 
consist of laudable pus ; old abscesses frequently furnish a brown or 
chocolate-colored pus that is discolored by the admixture of bile or of 
blood from neighboring vessels which have opened into the cavity of 
the abscess. Microscopical examination of the pus indicates a great 
amount of fatty degeneration of pus corpuscles, with abundant debris, 
microorganisms, and cholesterine tablets. 

The liver is usually much enlarged. The tissues around the abscess 



DISEASES OF THE HEPATIC PARENCHYMA. 389 

are in a state of inflammation, by which a connective-tissue capsule is 
formed around its cavity. The biliary passages are frequently dilated, 
especially when the abscess compresses the common bile-duct, or the 
hepatic duct. The portal vein may also suffer similar compression, by 
which ascites and tumefaction of the spleen are produced. 

A superficial abscess, or a deep abscess that has worked its way near 
the surface, excites inflammation of that portion of the peritoneal mem- 
brane by which it is overlaid. In this way adhesions with neighboring 
organs are frequently produced, and the discharge of the abscess may 
be directed into some one of the abdominal or thoracic cavities or organs. 
In other cases the abscess may effect a communication with the abdom- 
inal wall, discharging itself externally at any point upon the surface of 
the body to which the pus has burrowed its way. Deep abscesses of 
the liver frequently fail to attain to an evacuation of their contents, 
which, therefore, become caseated, encapsulated, and sometimes calci- 
fied. The resulting cicatrices, when a number of abscesses occupy the 
liver, lead to its irregular constriction in a manner somewhat similar to 
that which is produced by syphilitic disease of the organ. In rare in- 
stances the contents of the abscess become transformed into a thin, 
colloid substance which somewhat resembles the concents of an echino- 
coccus cyst. 

During the course of pycemia, abscesses form in the liver, as well 
as in the lungs, in the brain, or in other organs of the body. The 
process is initiated by the entrance of microorganisms into the capilla- 
ries of the hepatic lobules, where they obstruct the circulation and 
poison the neighboring tissue cells with their excretions. The hepatic 
cells undergo a coagulative necrosis and disappear, while pus corpuscles 
are rapidly formed in their place. 

Symptoms. Small abscesses of the liver may frequently exist with- 
out exciting suspicion of their presence during life. In other cases the 
phenomena of an intermittent, hectic fever are developed. In still 
other cases the symptoms of typhoid fever exist. Sometimes the course 
of pulmonary consumption is closely counterfeited ; and, again, the 
occurrence of hepatic suppuration must be inferred from a sudden 
appearance of pus in the urine or in the feces, or in the vomited or 
expectorated matters, or by reason of the development of empyema or 
pericarditis. 

Typical cases of hepatic abscess are characterized by an enlargement 
of the liver, upon the surface of which a convex prominence, which 
cannot be referred to the gall bladder or to other causes, may be dis- 
covered. The region of the liver is prominent and painful on pressure, 
and every tumefaction which can be* made out upon its contour moves in 
unison with the respiratory movements. In superficial abscesses a fluc- 
tuation can sometimes be clearly distinguished, and the friction sounds 
of perihepatitis become audible in its vicinity. The recti muscles, 
especially the right muscle, are sometimes tense and painful on pres- 
sure. Icterus may be observed, if the inflammatory process involves 
the biliary passages, or if they are compressed by the abscess. There 
is complaint of fulness and throbbing pain which frequently extends 
from the hepatic region to the right shoulder and arm, or to the left 



390 DISEASES OF THE LIVER, ETC. 

shoulder if the abscess be located in the left lobe of the liver. The gen- 
eral health and spirits are depressed ; dyspnoea is sometimes experienced 
in consequence of the upward pressure that is exerted against the dia- 
phragm and the lungs. Sometimes there is intense fever which assumes 
an intermittent or hectic character. Cough, vomiting, and eructation 
are frequent incidents. The bowels are either constipated or relaxed, 
and the urine frequently exhibits a reduction of its solid constituents. 

Internal evacuation of the abscess is very liable to occur suddenly, 
and may be attended by alarming symptoms if accompanied by internal 
hemorrhage or interference with any of the vital functions. If several 
abscesses exist, their successive rupture may occasion a considerable 
variety of symptoms according to the locality and mode of evacuation. 

The duration of the disease is exceedingly variable. In certain cases 
a fatal result may be reached in the course of a few days, while in 
others the disease lingers for months or for years. 

Diagnosis. Hepatic abscess is sometimes mistaken for intermittent 
fever. In such cases antiperiodic remedies produce no effect. From 
pulmonary tuberculosis the disease may be distinguished by the absence 
of tubercle bacilli and pulmonary debris from the sputa. An echino- 
coccus tumor may be recognized by the hydatid thrill which it imparts 
on palpation. Malignant tumors must be differentiated by the history 
of the case, and by the presence of cachexia, or the evidence of malig- 
nant disease in other parts of the body. A distended gall bladder may 
be recognized by its uniform and cystic outline; in doubtful cases an 
exploratory puncture should not be neglected, smce it is unattended 
with danger. Abscesses and tumors which are unconnected with the 
liver may be recognized by the absence of movements that synchronize 
with the movements of respiration. An exudation in the rigid pleural 
cavity may usually be distinguished from a large abscess in the upper 
convexity of the liver by its horizontal surface, and by the change 
of level which accompanies changes of bodily position. Sudden 
evacuations of pus into any of the internal cavities or passages must 
be differentiated from local diseases of the corresponding organs before 
they can be referred to an hepatic abscess. 

Prognosis and Treatment. The prognosis is very unfavorable, 
especially in the absence of surgical treatment. Under such circum- 
stances over 75 per cent, of the cases are fatal : though under the most 
favorable conditions for surgical interference the mortality is not less 
than 45 per cent. The best results are obtained when the abscess is 
evacuated through the air passages. 

Cirrhosis of the Liver — Hepatitis Chronica Interstitialis. 

ETIOLOGY. Cirrhosis of the liver is produced by a chronic, diffuse 
inflammation of the interstitial connective tissue of the entire organ. 
This differs from circumscribed interstitial inflammations by the fact 
that it is developed simultaneously throughout the whole extent of the 
liver; consequently every local and partial inflammation of the connec- 
tive tissue which arises in the course of local diseases, like abscesses, 
cancers, tumors, and echinococci, must be excluded. 



DISEASES OF THE HEPATIC PARENCHYMA. 391 

The most common cause of cirrhosis is found in the use of strong 
alcoholic liquors ; wine and beer rarely produce the disease. It is 
sometimes observed in connection with metabolic disorders, such as 
gout or diabetes. Syphilis, malaria, tuberculosis, and other infective 
diseases not unfrequently excite cirrhosis of the liver. It is also 
produced by the action of phosphorus upon the organ. 

Another cause of cirrhosis is found in the invasion of the biliary 
passages by inflammation ; under such circumstances the disease is 
accompanied by jaundice and enlargement of the liver. Among elderly 
people a senile proliferation of the connective tissue sometimes occurs 
in association with endarteritis in other organs ; this may be undoubt- 
edly developed at a comparatively early period, in certain instances, as 
a consequence of premature old age. Sometimes chronic perihepatitis 
leads to an extension of the inflammatory process, by which the con- 
nective tissue of the liver is invaded, and cirrhosis is produced. 

In many cases, however, it is impossible to arrive at a positive 
opinion regarding the nature of the cause or causes by which the 
disease has been excited. 

Cirrhosis of the liver occurs more frequently among men than among 
women, and is usually developed during the period of active life. It 
is occasionally encountered among young children who have been 
allowed to indulge in alcohol, and they sometimes exhibit the disease 
as a consequence of syphilis, or tuberculosis, or other infective diseases. 

Pathological Anatomy. Atrophic cirrhosis of the liver com- 
mences with an enlargement of the organ which, finally, is succeeded 
by atrophy and reduction in size, though it is not an uncommon inci- 
dent to find both processes going on together in the same liver, and 
transitional forms of the disease may also be observed. The atrophic 
process chiefly involves the left lobe of the liver; the organ may lose a 
half or two-thirds of its normal dimensions; its surface becomes uneven 
and nodulated; the peritoneal investment becomes thickened and fre- 
quently adherent to the neighboring structures. The gall bladder 
contains only a small amount of bile. The hepatic tissues appear con- 
densed, and their resistance to pressure and to incision is considerably 
increased. The organ presents a reddish-yellow color, from which the 
name of the disease was originally derived (mppdg, yellow) ; this pecu- 
liar color is dependent upon fatty degeneration of a portion of the liver 
cells, and the overloading of the remainder with pigment. The con- 
nective tissue is visibly increased in amount, and forms irregular 
capsules by which lobular groups are inclosed. Occasionally, a single 
lobule is thus encapsulated; but, under either condition, the result is 
the same — compression and atrophy of the cells of the parenchyma. 
The surface of an incision presents a roughened and granular appear- 
ance by reason of the protrusion of the hepatic elements which are thus 
relieved from pressure, hence the term granular liver that is frequently 
applied to this form of the disease. 

If the vessels of the liver be injected, the branches of the portal 
vein exhibit a great degree of impermeability, while the hepatic artery 
and the hepatic duct readily allow the passage of the injection. 

Microscopical examination indicates extensive proliferation of em- 



392 DISEASES OF THE LIVER, ETC. 

bryonic cells in the connective tissue, and inflammation of the minute 
branches of the portal vein ; by the pressure thus exerted upon the 
hepatic cells, and by the consequent interference with their nutrition, 
as well as by the direct effects of alcohol and bacterial or other poisons, 
the secreting structures of the lobules are progressively destroyed. 
The liver cells exhibit fatty degeneration, displacement of their nuclei, 
and infiltration with bile. In this way the glandular structure of the 
lobule is, finally, broken down and replaced by a mass of pigment and 
detritus. By many excellent observers it is believed that the entire 
process is initiated in the cellular structure of the parenchyma which 
undergoes a process of degradation through the influence of alcohol or 
through poisons, while the changes in the connective tissue are of a 
secondary nature. In accordance with either hypothesis the final 
result is the same. 

Jaundice rarely accompanies cirrhosis of the liver, because the biliary 
passages usually remain unobstructed. The portal circulation bears the 
brunt of the disease, and, consequently, the peritoneal cavity is often 
occupied by a dropsical transudation ; the spleen is enlarged, and the 
g astro-intestinal mucous membrane exhibits catarrhal inflammation ; 
the kidneys are not unfrequently involved in an inflammatory process 
that may be dependent upon the same causes which have excited cir- 
rhosis of the liver ; the intra-thoracic organs are, also, frequently invaded 
by diseases of a degenerative and dropsical character. 

The so-called biliary form of hepatic cirrhosis is attended by great 
enlargement of the liver, which sometimes doubles its normal size ; the 
entire organ is enlarged, and its structure is so condensed that it pre- 
sents unusual resistance to pressure and to incision. The color of the 
organ is yellow or gray. The interlobular connective tissue is greatly 
increased, so that each lobule is encapsulated by the proliferating tissue. 
The interlobular bile-ducts are also involved in the inflammatory process, 
and the biliary capillaries are increased in number throughout the 
peripheral portion of each lobule. Their epithelial lining exhibits greater 
thickness, by which the flow of bile is considerably impeded. The 
newly formed connective tissue invades the territory of the lobules, and 
presses between the liver cells as far as the central vein itself. In this 
w T ay the hepatic cells are compressed and atrophied. Unlike the inter- 
lobular inflammation by which atrophic cirrhosis is produced, biliary or 
hypertrophic cirrhosis is characterized by the simultaneous occurrence 
of inter- and intra-lobular proliferation of connective tissue. In this 
last form of the disease the proliferating tissues do not undergo the con- 
traction that is so conspicuous a feature in atrophic cirrhosis. For the 
same reason the hypertrophic form of cirrhosis is usually attended by 
jaundice, and runs its course without the development of ascites, since 
the portal circulation does not undergo the obstruction which arises in 
the course of atrophic cirrhosis. The spleen also becomes tumefied, 
probably through the influence of the same causes that produce hepatic 
enlargement. The liver does not undergo fatty degeneration, since the 
course of the circulation is not sufficiently obstructed to excite that 
process. 

Syphilitic cirrhosis of the liver is characterized by a tendency to 



DISEASES OF THE HEPATIC PARENCHYMA. 393 

irregular contraction and lobulation of the liver. The cirrhotic process 
involves the individual cells of the parenchyma, which become separately 
encapsulated by proliferation of the connective tissue. Senile cirrhosis 
of the liver is characterized by extensive endarteritis and obliteration of 
the vessels. The interlobular veins are greatly dilated, and in other 
respects the appearances of atrophic cirrhosis are present. 

Cirrhosis of the liver that is caused by phosphorus poisoning com- 
mences in the cells of the parenchyma, and the interstitial inflammation 
follows as a secondary consequence. In like manner malarial cirrhosis 
is caused by the poisonous action of malaria and bile pigments which 
invade the cells of the parenchyma, and there originate the processes 
which result in proliferation of the connective tissue. It is probable 
that both forms of cirrhosis may be thus originated. 

Symptoms. Atrophic cirrhosis of the liver commences insidiously 
with the symptoms of gastro-intestinal catarrh. Only when the liver 
begins to exhibit changes in its magnitude, or when dropsical accumula- 
tion occurs in the peritoneal cavity, can the disease be certainly recog- 
nized. At first, the liver appears to be enlarged, its lower border may 
extend below the navel, but this is succeeded by notable contraction of 
the organ. In certain cases the nodular surface of the liver can be felt 
through the abdominal wall, and the friction sounds of perihepatitis can 
be recognized. The occurrence of ascites is an important symptom, 
though it only indicates an obstruction in the course of the portal cir- 
culation. Peritoneal effusion, and compression of the portal vein by 
tumors, or its constriction by abdominal diseases, or by pylephlebitis, 
must be excluded before the diagnosis of cirrhosis can be established 
upon the basis of a dropsical accumulation in the peritoneal cavity. 
Frequently the dropsical liquid must be evacuated before the liver can 
be subjected to an examination. 

The spleen is usually very considerably enlarged as a consequence of 
portal obstruction ; though in certain cases its connective tissue under- 
goes proliferation under the influence of the same causes which have 
excited the process in the liver. Previous inflammation of the splenic 
capsule would, of course, prevent the tumefaction of the organ. 

The progress of cirrhosis is accompanied by progressive emaciation, 
and by an earthy discoloration of the skin which indicates grave inter- 
ference with the nutrition of the blood. The distended abdomen con- 
trasts strongly with the thin and wasted limbs. Upon the surface of 
the belly the veins appear greatly dilated and tortuous, in consequence 
of the compensatory circulation of the blood through abnormal channels, 
in order to reach the heart without passing through the portal vein and 
the inferior vena cava. The inferior epigastric veins anastomose with 
the superior epigastric veins and the mammary veins, which, in their 
turn, give passage to the blood by a retrograde course into the veins 
which enter the superior vena cava. In like manner, a portion of the 
portal blood is forced through the umbilical vein, and reaches the 
branches of the epigastric veins in the neighborhood of the umbilicus, 
forming around the navel a circle of dilated vessels which has anciently 
received the name caput Medusae, from a fancied resemblance to the 
snaky locks of that mythological personage. 



394 DISEASES OF THE LIVER, ETC. 

In addition to the serious disturbances of digestion which occur, the 
urine is generally diminished in quantity, and deposits a copious sedi- 
ment of urates. Albumin may be present, either as a consequence of 
nephritis or of the cachexia that is produced by blood stasis. 

The course of the disease is very tedious, since it covers from three 
to five years. 

As complications of the disease are sometimes observed hemorrhages 
either from the stomach or from the hemorrhoidal veins, though haemor- 
rhoids are not commonly present. Blood is sometimes discharged from 
the bladder or from varicose veins in the oesophagus. The respiratory 
organs and the heart are sometimes greatly incommoded by the pressure 
from ascites. Peritoneal tuberculosis sometimes occurs, either alone or 
in association with pulmonary tuberculosis. Retinal hemorrhage and 
inflammation are sometimes developed, and xanthopsia has been noticed, 
probably as a consequence of jaundice. Fever is usually absent, though 
it may be developed in the course of the disease, and may assume an 
intermittent form. 

Death frequently results from exhaustion. Sometimes it is preceded 
by the symptoms of dissolution of the blood, or by diarrhoea and intes- 
tinal hemorrhage, or by other intercurrent diseases. Occasionally, 
death results from cholsemia, which is probably caused by the inability 
of the liver to eliminate excrementitious matters and biliary constituents 
from the blood. The patients become restless and delirious, and sink 
into a typhoid condition, which may be accompanied by convulsions 
before the fatal termination. 

Biliary or hypertrophic cirrhosis of the liver is indicated by great 
enlargement of the liver and spleen without the complication of ascites 
and enlargement of the external abdominal veins. Jaundice and diar- 
rhoea are very common incidents. The disease usually lingers for six 
or seven years, and is often terminated by the occurrence of fever, de- 
lirium, and coma. 

Syphilitic cirrhosis of the liver generally runs its course without any 
notable exhibition of ascites or jaundice or venous dilatation. 

Diagnosis. In cases that are complicated by dropsy, the diagnosis 
is often impossible before the liquid has been evacuated. The diseases 
which may be confounded with cirrhosis of the liver are: (1) Amyloid 
degeneration of the liver, which is characterized by dropsy and enlarge- 
ment of the liver and spleen, but is preceded by chronic suppuration or 
by the development of syphilitic or malarial cachexia. The urine is 
albuminous, jaundice is absent, and general dropsy is present. (2) 
Cancer of the liver is rarely associated with enlargement of the spleen ; 
it usually occurs at an advanced period of life, and is accompanied by 
the development of cancerous disease in other organs or in the lymph 
glands. The evidences of cancerous cachexia are also present. (3) 
Gummy tumor of the liver may be recognized by the history of the 
patient, and by other evidences of syphilitic disease. (4) Pylephlebitis 
is characterized by the very rapid development of the symptoms of 
obstruction in the course of the portal circulation. (5) Vascular en- 
gorgement of the liver is usually characterized by the presence of the 
causes of hepatic hyperemia. (6) Chronic peritonitis presents the 



DISEASES OF THE HEPATIC PARENCHYMA. 395 

phenomena of pain, tenderness, and universal inflammation over the 
whole abdominal region. 

Prognosis. The prognosis is of the most unfavorable character, 
though recovery does in rare instances occur. 

Treatment. The use of alcohol must be entirely abandoned, and 
the diet should consist chiefly of milk. If the liver be enlarged, laxa- 
tive mineral waters may be used with advantage. Leeches may be 
applied to the anus, and cups over the region of the liver. Painful 
conditions must be relieved by poultices. Malarial cases require the 
administration of anti-periodic remedies, with a change of locality to a 
healthy residence. Syphilitic cases should be treated with iodide of 
potassium and mercurials. The hypertrophic form of cirrhosis is bene- 
fited by the administration of ammonium chloride, in three-grain doses 
every three hours, or by the use of calomel and jalap, of each five grains 
every day, for three days in each week during the space of one or two 
months. The operation of tapping for dropsy should be performed at a 
comparatively early period, and should be repeated as often as may be 
necessary for the relief of discomfort, since its frequent repetition is some- 
times followed by the permanent disappearance of dropsical symptoms. 

Acute Yellow Atrophy of the Liver — Atrophia Hepatis Acuta Flava. 

Etiology. Acute yellow atrophy of the liver is characterized by a 
rapid, fatty degeneration and destruction of the hepatic cells, and by 
reduction in the bulk of the organ. The disease is exceedingly rare, 
and may occur either as a primary affection, or as a secondary con- 
sequence of previous diseases of the liver or of the entire body. 

Primary yellow atrophy of the liver is more common among women 
than among men. It is usually encountered during middle life, and is 
often observed in connection with pregnancy, especially during the later 
portion of that period. Its exciting causes are frequently associated 
with emotional agitation or with alcoholic excess. Phosphorus poisoning 
has been assigned, in certain cases, as a cause of the disease, but the 
degeneration that is produced by phosphorus is certainly different from 
acute yellow atrophy of the liver. 

The secondary variety of yelloiu atrophy of the liver is sometimes 
observed as a circumscribed and local affection associated with fatty 
liver, and cirrhosis, or with certain infective diseases. 

Pathological Anatomy. Acute yelloiv atrophy produces great 
reduction in the size of the liver ; its substance becomes flaccid, and 
presents various tints of a brilliant yellow color. The gall bladder is 
nearly empty, or contains a small quantity of viscid, yellow bile. 
Microscopical investigation indicates fatty degeneration of the liver 
cells, and complete destruction of their organization. Among the debris 
may be observed crystals of bilirubin and tyrosin. Microorganisms are 
sometimes present, though no special variety has yet been discovered to 
account for the disease. 

The blood is thin, dark, and reduced in quantity. The organs are 
stained with bile pigment, and in many instances hemorrhages are 
observed in different parts of the body. The abdominal lymph glands 



396 



DISEASES OF THE LIVER, ETC. 



are frequently tumefied and distended with blood. The spleen is 
enlarged and softened. The g astro-intestinal mucous membrane ex- 
hibits evidences of catarrhal inflammation. The epithelium of the 
tubuli uriniferi has undergone fatty degeneration, and the tubules 
sometimes contain leucin, tyrosin, and crystals of hsematoidin. The 
muscular fibres of the heart exhibit fatty degeneration, and the lungs 
are sometimes inflamed. The pleural cavities, the pericardium, and 
the meninges of the brain are occupied by a serous exudation. The 
striated muscles have sometimes undergone fatty degeneration. 

Symptoms. The course of yellow atrophy is marked by two stages. 
During the first, the symptoms are introduced by the evidences of gastro- 
intestinal catarrh, which is followed by jaundice, beginning in the face 
and gradually extending over the body. This period may occupy sev- 
eral days or weeks. 

The second stage of the disease is characterized by severe nervous 
symptoms. The patient becomes restless and delirious, screaming and 
endeavoring to get out of bed ; spasmodic contractions of the muscles 
and paroxysms of trismus are developed ; consciousness is progressively 
overwhelmed ; coma is developed ; the breathing becomes irregular and 
stertorous ; and death occurs in a state of complete insensibility. During 
this time the liver rapidly diminishes in size ; the process commences in 
the left lobe of the organ, and advances until the area of dulness is 
almost completely abolished. Pressure over the region of the liver ex- 
cites evidences of pain. The spleen is usually enlarged, though such 
tumefaction may not be developed when copious hemorrhage from the 
intestinal canal reduces blood pressure, or if the spleen have been pre- 
viously bound down by adhesions and inflammations of its capsule. 
Jaundice is almost always present, and a roseolous eruption, or petechias 

and subcutaneous extravasations of 
blood may be observed. The urine 
is diminished or even suppressed be- 
fore death ; its reaction is acid, and 
its color is like that of the urine in 
jaundice, though the pigmentary re- 
action of bile cannot always be dis- 
covered. The sediment contains a 
considerable quantity of leucin and 
tyrosine which possess great path- 
ognomonic importance. (Fig. 90.) 
Hyaline casts are often remarked. 
Chemical examination indicates a 
reduction of urea, and its replace- 
ment by less highly oxidized com- 
pounds of nitrogen. 

The tongue is coated, and the lips 
and teeth are often covered with 
sordes. There is, frequently, vomit- 
ing of blood, or of coffee-ground pigments, from the stomach. The 
bowels are confined, the stools are scanty and destitute of bile. The 
later stages of the disease are often marked by hemorrhage from the 




Crystals of tyrosine deposited sponta- 
neously in the urine, from a case of acute 
yellow atrophy of the liver. (Roberts.) 



DISEASES OF THE HEPATIC PARENCHYMA. 397 

internal and external surfaces of the body. The pupils are generally 
dilated and sluggish. Fever may be absent during the whole course of 
the disease, and the temperature sometimes falls below the normal level, 
though it may rise extraordinarily before death. The pulse exhibits all 
the various indications of an enfeebled heart. 

The course of the disease is rarely prolonged beyond a week. 

Acute yellow atrophy is probably a local disease of the liver, though 
whether it be due to the action of microorganisms is not positively 
decided. The actual causes of the disease, at present, remain undis- 
covered. 

Diagnosis. Acute yellow atrophy of the liver may be differentiated 
from jaundice by rapid diminution in the bulk of the liver, and by the 
speedy termination of the disease in death. Cirrhosis of the liver may 
also be excluded by the rapid progress of atrophy. Phosphorus poison- 
ing can only be differentiated by the history of the case, or by the dis- 
covery of phosphorus in the ingesta. 

Prognosis and Treatment. The prognosis is invariably bad, and 
the treatment can only be of a symptomatic character. 

Fatty Liver — Hepar Adiposum. 

Etiology. Fatty infiltration consists in an unusual deposit of fat 
in the liver as a consequence of excessive feeding with fats and oils, 
while fatty degeneration consists in the deposition within the liver cells 
of fat that is derived from the decomposition of their albuminous con- 
stituents. 

Fatty infiltration is usually observed in persons who consume large 
quantities of sugar, starch, fat, and alcohol. It is a frequent accom- 
paniment of obesity. Fatty degeneration follows those conditions in 
which the liver cells receive an insufficient amount of oxygen through 
the blood; or it may accompany cachexia of every kind. The same 
form of degeneration is sometimes observed as a consequence of high 
temperature in fevers, especially in the course of infective diseases. It 
may also result from poisoning with phosphorus, arsenic, antimony, and 
ethereal preparations which hinder the access of oxygen to the tissues. 
Fatty degeneration is also favored by obstacles in the course of the cir- 
culation ; and it is frequently recognized in connection with local dis- 
eases of the liver. 

Pathological Anatomy. A moderate degree of nitty degeneration 
can be recognized only by the aid of the microscope ; but, when the 
process has reached any considerable extent, the liver appears enlarged, 
and it may more than double its normal size. The organ is pale, like 
yellow soap ; its consistence is soft and flaccid, while yet warm from the 
recent subject. The serous investment is smooth, and stellate blood- 
vessels are visible beneath its surface. The gall bladder contains a 
small quantity of bile. On section the boundaries of the lobules appear 
ill-defined ; however, if blood stasis or biliary obstruction have preceded 
death, the central portion of the lobule may be colored a dark-red or 
bilious hue. The tissues feel greasy, and impart a greasy stain to 
bibulous paper. Microscopical investigation reveals a condition in 



398 DISEASES OF THE LIVER, ETC. 

which the hepatic cells are filled with minute fat globules. In severe 
cases the liver cell may be occupied by a single globule of fat. 

Chemical examination of the organ indicates that in fatty infiltration 
the liver cells contain oil that is stored up at the expense of the watery 
constituents of the tissue: while in fatty degeneration the fattv deposit 
takes place at the expense of the albuminous constituents, without ex- 
pulsion of water. 

Waxy liver is a term that has been applied to a variety of fatty liver 
in which the organ presents a waxy appearance, probably in consequence 
of a preponderance of palmitin and stearin. 

Symptoms. In moderate cases of fatty liver the disease may escape 
recognition during life ; but, when the organ has become considerably 
enlarged, there is complaint of pressure and of pain in the hepatic region. 
As a consequence of progressive obstruction to the portal circulation 
and to the excretion of bile, there are symptoms of loss of appetite, 
nausea, vomiting, diarrhoea, gray-colored stools, and often haemorrhoids ; 
jaundice, ascites, and enlargement of the spleen do not occur, since the 
retrograde pressure of the blood is not sufficient to produce such inci- 
dents. 

Diagnosis. Fatty liver may be suspected among drunkards and 
gluttons, especially when there is enlargement of the organ without the 
ascites and tumefaction of the spleen which are frequently present in 
cirrhosis. Amyloid liver differs from fatty liver by the presence of 
general dropsy and albuminuria ; and the lower border of the organ is 
more sharply defined, and more resistant than in fatty enlargement. 

Prognosis and Treatment. The prognosis depends upon the 
causes of the disease, which by itself is seldom fatal. The treatment of 
fatty liver must depend upon its causes and upon the general condition 
of the patient. 

Amyloid Liver — Hepar Amyloideum. 

Etiology. Amyloid liver is almost invariably a secondary disease 
that is developed as a consequence of cachectic conditions which arise in 
the course of chronic suppuration, ulceration, malarial poisoning, syphilis, 
exhausting discharges, and wasting diseases. It only occurs as a con- 
genital disease in hereditary syphilis. It is more frequent among men 
than among women, and is generally encountered between the ages of 
ten and fifty years. 

Pathological Anatomy. The size of the liver may be very greatly 
increased ; in certain instances it has been known to occupy the space 
between the third rib and the crest of the ilium on the right side of the 
body. Its serous investment is smooth, tense, and free from adhesions. 
The substance of the organ is firm and dense, almost as if it had been 
frozen. On incision the cut surface of the part appears like bacon, and 
thin sections are translucent. The hepatic lobules appear almost totally 
obliterated. If a section of the organ be treated with a solution of 
iodine (Iodin. 1, potass, iodid. 2, aquae 100), and then washed in pure 
water, the amyloid portions appear of a mahogany brown color. 



DISEASES OF THE HEPATIC PARENCHYMA. 399 

The branches of the "portal vein and of the hepatic artery offer no 
obstacle to injections, and the gall bladder is nearly empty. 

When the process of amyloid degeneration is somewhat restricted, it 
is most conspicuous in the intermediate zone between the central and 
the peripheral portions of the hepatic lobules. Here the mahogany 
color which follows treatment with iodine contrasts strongly w 7 ith the 
fatty cells of the peripheral portion and the bile-stained tissue that 
surrounds the central vein of the lobule. Microscopical examination 
indicates the participation of the minute arterial structures of the liver 
in the amyloid process, which, at a later period, may invade the capil- 
lary vessels, and may, occasionally, attack the veins ; hence the early 
appearance of amyloid degeneration in the middle third of the lobule 
where the terminal twigs of the hepatic artery communicate with the 
portal system. From this point the degenerative process extends to- 
ward the central vein ; and, last of all, occupies the peripheral portion 
of the lobule, together with the interlobular branches of the portal vein. 
The cells of the parenchyma do not to any great extent participate in 
the process. It is not yet decided whether the invasive process is a true 
degeneration that originates upon the spot, or whether it consists in the 
infiltration of the tissues with matter from without. The amyloid pro- 
duct appears to be an albuminoid substance which yields leucin and 
tyrosin like other albuminous substances. 

Symptoms and Diagnosis. Amyloid degeneration may often exist 
for a considerable period of time without specific symptoms. In certain 
cases it presents only the consequences of mechanical inconvenience 
occasioned b} r the increasing volume of the liver and of the spleen ; in 
other instances there is loss of appetite, vomiting, and diarrhoea, with 
an absence of bile from the stools ; and if the kidneys participate in 
the disease, albumin may be discovered in the urine. Universal pallor 
and dropsy finally occur. Jaundice is not observed unless an accidental 
compression of the common bile-duct has taken place. The duration 
of the disease extends over many years. Death results from exhaus- 
tion, dropsy, or intercurrent diseases. 

Prognosis and Treatment. The prognosis is always unfavorable, 
though recovery has been occasionally reported. The treatment must 
depend upon the nature of the diseases which have originated the degene- 
rative process. 

Cancer of the Liver — Carcinoma Hepatis. 

Etiology. Cancer of the liver is a comparatively common disease. 
It is usually encountered in later life, after the fortieth year, and is 
more frequent among women than among men, by reason of its second- 
ary connection with cancerous diseases of the female generative appa- 
ratus. It is less common in warm climates than in cold. It sometimes 
follows injuries, and it may be developed as a consequence of the impac- 
tion of gall-stones in the biliary passages. 

Primary cancer of the liver is a rare disease ; but secondary cancer 
is of frequent occurrence, especially when preceded by primary cancer- 



400 DISEASES OF THE LIVEE, ETC. 

ous disease in the territory occupied by the portal circulation and its 
collateral dependencies. 

Pathological Anatomy. Cancer of the liver may occur either in 
a circumscribed or in an infiltrated form. Secondary cancer almost 
always belongs to the circumscribed variety, and exists as a sharply de- 
fined tumor which contrasts strongly with the remaining portions of the 
organ. Cancerous tumors of the liver may be either single or multiple, 
and their size varies from that of a pin's head to the magnitude of a 
cocoanut, or even larger. In certain cases the liver has been found to 
occupy the entire space between the second rib and the crest of the 
ilium. On the contrary, small tumors may only come to light on in- 
cision of the organ. When they involve the superficial portion of the 
liver, the projecting mass is frequently characterized by a central de- 
pression that is caused by a greater contractility in those central por- 
tions of the tumor which receive less nourishment than the peripheral 
parts. 

Primary cancers of the liver originate in the epithelial cells of the 
biliary passages, or in the hepatic cells of the lobules, which become 
transformed into cancerous tissue. Secondary cancers exhibit the same 
histological structure that characterizes the parent tumor. All forms of 
cancerous growths may be observed. Frequently, the biliary passages 
and the blood and the lymph vessels of the liver are invaded by the 
progressive growth ; and in this way the disease may be transmitted 
through the ordinary channels of circulation into other organs. 

Cancerous infiltration of the liver closely resembles the appearances 
observed in cirrhosis. Microscopical examination, however, indicates 
the nature of the disease. 

The portal lymph glands usually participate in the degenerative pro- 
cess in connection with all forms of hepatic cancer ; and. by their 
pressure, may interfere with the circulation of the blood or of the bile. 

Symptoms. Cancer of the liver may remain unrecognized either in 
consequence of its limited extent, or by reason of the severity of the 
symptoms which accompany the primary forms of disease by which it 
is conditioned. The principal symptoms depend upon mechanical and 
functional changes in the liver. The organ may be greatly enlarged, 
and the tumor may be distinguished from other tumors which are dis- 
connected with the liver by its motion in harmony with the movements 
of respiration. When several tumors occupy the surface of the liver, 
their nodular prominences can be frequently distinguished through the 
abdominal wall ; they are generally hard, and, sometimes, their umbili- 
cated form can be recognized. There is almost always complaint of pain. 
which is either spontaneous or occasioned by pressure over the liver : 
this pain is sometimes lancinating, and frequently extends to the shoulder 
or into the pelvis. Jaundice is frequently observed : but only when the 
biliary passages are compressed by the tumor or by degenerated lymph 
glands. The discoloration of the skin speedily increases under such 
circumstances, and may reach a very high degree of dark pigmentation 
(melanismus). Emaciation progresses speedily : the extremities become 
oedematous; occasionally the jugular lymph glands become enlarged, 
though less frequently than when the stomach is the seat of cancerous 



DISEASES OF THE HEPATIC PARENCHYMA. 401 

growth. The inguinal glands, in like manner, sometimes become en- 
larged. The temperature generally remains normal, or subnormal ; 
occasionally, the symptoms of fever are manifested ; consciousness 
ordinarily remains perfect until the end of life, though sometimes the 
delirium of inanition occurs during the last stage of the disease. 

In many instances, insomnia and terrible cutaneous itching, without 
apparent cause, are experienced ; appetite and digestion fail ; the tongue 
becomes dry and brown ; vomiting is not uncommon ; the bowels are 
generally confined ; and the urine is scanty and high-colored. Indican 
is present in considerable quantity ; and, sometimes, albumin may be 
discovered. The spleen is sometimes enlarged ; peritoneal dropsy is a 
common incident, either in connection with general dropsy, or as a re- 
sult of local interference with the portal circulation. The red blood- 
corpuscles are reduced in number, and present a great variety of forms 
and dimensions (poikilocytosis) ; the white corpuscles are sometimes in- 
creased in number, and the hemoglobin is greatly reduced in amount. 

The course of the disease is very rapid in young patients ; the aver- 
age duration of the disease is from a year and a half to two years and 
a half. Death may result from exhaustion ; from internal hemorrhage ; 
or from the consequences of the eruption of the tumor into the perito- 
neal cavity or other cavities and passages of the body. It may also 
result from a variety of intercurrent causes. 

Diagnosis. The diagnosis of hepatic cancer is sometimes attended 
with great difficulty. In certain cases, icterus is the only acute symp- 
tom, so that when chronic jaundice is associated with progressive emaci- 
ation and failure of strength on the part of an elderly patient, hepatic 
cancer should be suspected. When a tumor can be recognized, it may 
be differentiated from tumors that are disconnected with the liver, by 
its participation in the respiratory movements ; from hepatic tumors it 
may be differentiated by attention to their characteristic symptoms. A 
distended gall bladder is smooth, tense and pear-shaped. Abscesses of 
the liver, and large echinococcus cysts exhibit fluctuation. Syphilitic 
tumors may be recognized by their history and association with other 
symptoms of syphilis. It is often very difficult, if not impossible, to 
distinguish between hepatic cancer and a similar disease in the stomach, 
since all the ordinary evidences of gastric cancer may be produced by 
malignant disease in the liver alone. 

Prognosis and Treatment. The prognosis is inevitably bad, and 
the treatment must be purely symptomatic. 

Sarcoma and Adenoma of the Liver present no clinical symptoms by 
which they can be positively differentiated from ordinary cancer of the 
organ. Other neoplasms which involve the liver may be studied in 
special works on Pathological Anatomy. 

Women who have given birth to many children, and persons whose 
abdominal tissues exhibit unusual laxity, sometimes present the symp- 
toms of wandering liver. The organ is displaced from its ordinary 
situation, and falls into the lower portion of the abdomen, where it 
swings upon its elongated attachments. Sometimes an intestinal fold 

26 



402 DISEASES OF THE 

becomes interposed between the upper surface of the organ and the 
diaphragm, so that a distinctly tympanitic sound can be recognized in 
the hepatic fossa, while the lower portion of the abdomen is occupied 
by the liver, whose form can be distinguished through the abdominal 
wall when that is not overlaid with fat. The only treatment that is 
possible consists in mechanical support by properly fitting belts and 
bandages. 

In rare instances a transportation of the abdominal organs has been 
observed, in which the liver and the spleen have exchanged places. 
Hernial protrusion of the liver through the diaphragm has also been 
observed. 

Among women who wear tight corsets the liver is frequently deformed 
by the development of a furrow at the line where constriction is the 
greatest (corset liver). The hepatic tissue becomes atrophied and use- 
less along the line of constriction. In certain cases the organ appears 
as if divided by this horizontal furrow, so that the lower segment resem- 
bles a tumor or mere appendage of the organ ; and, occasionally, the 
mass has been removed by surgical operation. 



CHAPTEE III. 

DISEASES OF THE HEPATIC BLOODVESSELS. 

Portal Thrombosis — Pylethrombosis. 

Etiology. Sufficient retardation of the arterial circulation in asso- 
ciation with fatty degeneration of the vascular walls may give occasion 
for the formation of thrombi within the trunk, or in the branches of 
the portal vein. More frequently, however, the process results from 
compression of the vessel during the course of hepatic diseases. It is, 
therefore, not uncommon in cirrhosis of the liver, or in obstruction of 
the biliary passages, or as a consequence of pressure exerted by tumors 
which encroach upon the portal vein. 

Pathological Anatomy. On opening the portal vein its lumen 
may be found occupied by a thrombus, which, according to its age, 
either resembles a fresh clot, or exhibits various degrees of decoloration. 
The vascular walls may be in a state of simple hypertrophy, or fatty 
degeneration, or calcification. 

Symptoms. Extensive occlusion of the portal vein is attended by 
the symptoms of obstruction in the course of the portal circulation. 
The spleen becomes enlarged, the digestive organs present all the symp- 
toms of passive congestion, and the peritoneal cavity becomes distended 
with fluid. The duration of the disease may cover many months or 
years, and death follows from exhaustion. 



DISEASES OF THE HEPATIC BLOODVESSELS. 403 

Diagnosis, Prognosis, and Treatment. It is scarcely possible to 
differentiate portal thrombus from cirrhosis of the liver; and chronic 
diseases of the peritoneum frequently counterfeit its course. The prog- 
nosis is unfavorable ; and the treatment is essentially the same that is 
required for cases of cirrhosis. 

Suppuration of the Portal Vein — Pylephlebitis Suppurativa. 

Etiology. Suppuration of the portal vein is almost always the 
secondary consequence of inflammatory and ulcerative processes in 
those organs which originate the portal system. It is, therefore, 
usually observed as a sequel of intestinal inflammation or ulceration, 
and may be associated with hsemorrhoidal tumors, or with operations 
upon the rectum. 

Pathological Anatomy. Suppurative inflammation may be re- 
stricted to a limited portion of the hepatic branches of the portal vein, 
or it may involve the whole trunk and periphery of the portal system. 
The walls of the vessel are thickened, softened, sometimes ulcerated, 
and its lumen contains various kinds of pus. The liver and the spleen 
are generally enlarged, and small abscesses are not uncommonly ob- 
served. In certain cases the suppurative process invades the other 
structures of the body, and the phenomena of general pyaemia are dis- 
played. 

Symptoms. The symptoms are frequently those which characterize 
deep-seated suppurative processes. Fever of a hectic character, pain 
on pressure over the region of the liver, and the evidences of metastatic 
suppuration in other parts of the body, form the general features of 
the disease. In many cases a typhoid condition is developed, and death 
is preceded by the symptoms of delirium and coma. The duration of 
the disease seldom covers more than two weeks. 

Diagnosis. The disease may be easily mistaken for abscess of the 
liver, but in such cases there is no enlargement of the spleen, and diar- 
rhoea is present. Biliary colic rarely occasions symptoms of profound 
and general disorder. The stools are clay-colored, while the urine 
contains bile pigment. 

Catarrhal jaundice is unattended by the chills and rapid failure of 
strength which mark the course of pylephlebitis. Typhoid fever is 
characterized by the absence of jaundice, by the characteristic tempera- 
ture curve, by the presence of roseola, and by the appearance of typhoid 
bacilli in the blood and stools. Intermittent fever rarely exhibits 
symptoms of jaundice, and yields readily to quinine. 

Prognosis and Treatment are exceedingly unsatisfactory. 

The hepatic veins are occasionally invaded by inflammation or by 
thrombus, but they present no characteristic symptoms, and the morbid 
conditions are merely developed in concurrence with other hepatic 
diseases. 



404 DISEASES OF THE LIVER, ETC. 

CHAPTER IV. 

DISEASES OF THE PANCREAS. 

The pancreas may be invaded by inflammation, or by malignant 
disease. Hemorrhage into its substance may occur in the course of 
other diseases that are accompanied by dissolution of the blood. The 
symptoms of these disorders are masked by the symptoms of the pri- 
mary diseases with which they are connected. 

Scirrhus and other cancerous diseases sometimes involve the pan- 
creas, more frequently among men than among women, at an advanced 
period of life. The symptoms are very obscure, and often the existence 
of a pancreatic tumor can only be inferred from the progressive cachexia, 
or from the evidences of pressure upon the portal vein and common 
bile-duct that cannot be referred to causes involving other abdominal 
organs. 

Cysts sometimes develop in the pancreatic glands, and may reach 
dimensions which necessitate their extirpation by surgical methods. 
Their nature may be inferred from their position behind the stomach, 
whence they protrude into the epigastrium, and by the fact that an ex- 
ploratory puncture brings to light a bloody fluid which is rare in the 
ovarian cysts for which pancreatic cysts are sometimes mistaken. 

The mesenteric glands are usually enlarged in connection with the 
majority of the diseases that affect the organs with which they com- 
municate. They frequently undergo malignant degeneration, and be- 
come greatly enlarged, so that they may exert a very injurious pressure 
upon other abdominal organs and passages. 



CHAPTER V. 

DISEASES OF THE PERITONEUM. 

Inflammation of the Peritoneum — Peritonitis. 

Etiology. Inflammation of the peritoneum may be either diffuse 
or circumscribed, acute or chronic. A case which begins as a diffuse in- 
flammation may terminate as a circumscribed affection of a limited portion 
of the peritoneal cavity ; while an originally circumscribed inflammation 
may extend and involve the whole sac. 

Peritonitis is directly caused by the action of microorganisms which 
excite inflammation, e.g., staphylococcus pyogenes aureus, pneumococ- 
cus, etc. The influence of cold and of injuries is limited to the estab- 
lishment of conditions under which microorganisms become active. 



DISEASES OF THE PERITONEUM. 405 

Rheumatism occasionally affords an opportunity for the develop- 
ment of peritonitis ; attacking the joints, it may disappear from those 
localities as inflammatory symptoms are manifested in the peritoneal 
territory. 

Peritonitis is frequently caused by the extension of diseases which 
produce or are accompanied by inflammation. In this way inflamma- 
ations and tumors of the abdominal organs may excite the disease. It 
not unfrequently results from perforation of the peritoneal sac by 
ulcers or abscesses or cancerous growths which are developed outside 
of the peritoneal cavity. 

Infective diseases are frequently accompanied or followed by peri- 
tonitis ; and it sometimes develops as a result of other diseases, such 
as cancer and tuberculosis, which have invaded the peritoneum. In 
spite of all these well-known causes there are cases in which no appar- 
ent reason can be discovered for the existence of peritonitis, though it 
is not improbable that in such cases infective microorganisms have 
found their way out of the alimentary canal or through the female gen- 
erative organs into the peritoneal cavity. 

Peritonitis is most frequently observed during the first few years of 
adult life. It is more common among women than among men because 
of their predisposition to puerperal diseases and septic infection. New- 
born children not unfrequently suffer from peritonitis, which has been 
derived from the mother through infection of the umbilical wound. 

Pathological Anatomy. As a consequence of the histological re- 
semblance between the peritoneum and the pleural membranes, identical 
consequences follow inflammation in either locality. Peritonitis may, 
therefore, exist as an adhesive inflammation (Peritonitis fibrinosa), or 
as a serous exudation (P. serosa), or as a purulent effusion (P. puru- 
lenta), or the products of inflammation may become putrescent (P. 
putrida), or mixed with blood (P. hemorrhagica). 

At the commencement of an attack of peritonitis the sub-serous 
bloodvessels become dilated and distended with blood, which reddens 
the surface of the membrane. The smooth, shining appearance of the 
peritoneum is exchanged for a dull and turbid layer. The endothelial 
cells become swelled, and are exfoliated. The membrane becomes over- 
laid with an exudation that consists chiefly of minute, fibrinous fila- 
ments which enclose in their meshes numerous embryonic cells. The 
opposite surfaces of the peritoneal sac are thus bound together by ad- 
hesive bands which become thickened and, sometimes, partially organ- 
ized. If the disease terminates at this point recovery takes place, and 
the adhesions remain more or less permanent. In this way, circum- 
scribed portions of the peritoneal sac may become divided from the 
main portion of the cavity, and bands may be formed, which, in later 
time, may become a source of danger through constriction or strangula- 
tion of the intestinal folds which they involve. Sometimes the process 
results in such an amount of contraction of the omentum and mesentery 
that the mobility of the intestines is greatly impaired. 

Sometimes a fibrinous exudation is followed by a serous effusion, by 
which the peritoneum is filled with a yellowish or slightly turbid liquid 
that contains flakes of fibrin and endothelial cells. If the cellular con- 



406 DISEASES OF THE LIVER, ETC. 

stituents of the effusion become numerous, a purulent peritonitis is the 
result ; if, then, as a consequence of putrefaction, the purulent effusion 
undergoes decomposition, the putrid for m of the disease is set up. Such 
decomposition may result from perforation of the alimentary canal and 
the passage of fecal matter into the peritoneal cavity. It sometimes 
happens, however, that a fecal odor is present although no communica- 
tion can be discovered between the cavity and the intestinal canal. 

Hemorrhagic peritonitis, like the serous form of the disease, usually 
runs a chronic course, and is associated either with cancer or tubercu- 
losis, or with the specially hemorrhagic diseases. In certain rare in- 
stances, the bloody effusion undergoes a certain low grade of organiza- 
tion, like what is observed under similar instances in the meningeal 
cavity of the brain, or in the pleural cavities. (Hematoma peritonei.) 

In many cases of purulent peritonitis the serous membrane becomes 
eroded and ulcerated ; sometimes, in this way, perforation of the walls 
of the cavity may be . produced, and the intestinal contents may thus 
escape into the ureters, or the bladder, or may find their way through 
the diaphragm into the thorax, or through the abdominal wall into the 
external world. If the abdominal vessels are thus penetrated, death 
follows, either as a consequence of hemorrhage or of pyaemia. In cer- 
tain cases, a purulent peritonitis may become encapsulated by the 
formation of adhesions ; the pus may finally undergo caseation or calci- 
fication. Under such circumstances tubercular infection is not an un- 
common sequel. 

Symptoms. Acute, diffuse, purulent peritonitis sometimes occurs 
suddenly ; or it may be preceded by chills and fever, with the ordinary 
symptoms which accompany a febrile movement ; pain is experienced 
in the umbilical region, or it may be diffused over the whole abdomen ; 
the slightest pressure becomes intolerable, and the patient lies continu- 
ally upon the back, with the knees bent, and the thighs drawn up to the 
belly, in order to relax the abdominal muscles as much as possible : 
every kind of movement which can involve the peritoneal surface is 
dreaded by the patient ; the abdomen is distended by the formation of 
gas, which remains imprisoned in the bowels by reason of the paralytic 
condition of the intestinal muscles ; the abdominal muscles are tense 
and rigid as a consequence of reflex excitation. Sometimes a distinct 
friction sound can be heard and felt over the abdominal wall. The 
presence of liquid effusion causes dulness and a sensation of fluctuation, 
if the patient can tolerate the examination that is necessary for its 
demonstration. 

Peritonitis almost always commences with vomiting, by which the 
contents of the stomach are evacuated. The vomited matters then 
assume a grass-green color; sometimes fecal vomiting takes place. As 
the disease advances to a fatal termination, vomiting is replaced by 
hiccough ; the tongue is usually coated, or red and dry : the bowels are 
semetimes loosened at the commencement of the disease, but generally 
they become closely confined ; the urine is reduced in quantity, and 
sometimes contains a little albumin ; indican is also present : urination 
is attended with pain and difficulty, especially when the serous invest- 
ment of the bladder is inflamed. The temperature is considerably 



DISEASES OF THE PERITONEUM. 407 

elevated, often reaching 105° F. The course of fever may be either 
continued, remittent, or intermittent ; the pulse is frequent, small, and 
weak. The countenance indicates intense pain and exhaustion ; the 
voice is sometimes reduced to a whisper ; consciousness is seldom dis- 
turbed, though delirium and spasms sometimes appear before a fatal 
termination ; respiration is hurried and shallow, in consequence of the 
upward pressure against the diaphragm ; the absence of diaphragmatic 
respiration constitutes an alarming symptom. As a consequence of 
abdominal distention, the lungs and the heart are forced upward ; the 
apex of the heart sometimes beats in the third intercostal space. 

Acute, purulent peritonitis generally terminates in death, though life 
may be prolonged for a number of days ; the fatal termination is some- 
times very abrupt, as if by shock ; in other cases it appears to result 
from asphyxia, by reason of the difficulties which obstruct respiration ; 
in other cases the patient passes into a state of collapse, or life termi- 
nates by septic poisoning. 

In certain instances the disease passes into the subacute and chronic 
form, which may continue for many w T eeks, and be accompanied by 
numerous complications. Spontaneous evacuation of pus may occur in 
any direction, or the peritoneal contents may become encapsulated, and 
apparent recovery may take place, though subsequent relapses are 
frequent. Under the most favorable circumstances, the sequelae of 
peritonitis are greatly to be feared. 

Puerperal peritonitis usually commences about four or five days after 
childbirth, with great distention of the abdomen, and the symptoms of 
diarrhoea or dysentery. There is less pain than in the ordinary form of 
peritonitis, and the course of the fever is frequently interrupted by 
severe chills. Purulent infection of the entire organism frequently fol- 
lows, and death usually occurs in the course of the second week of the 
disease. 

Acute, circumscribed peritonitis is that form of peritoneal inflamma- 
tion which is limited to the serous investment of the different abdominal 
organs, hence the term perihepatitis, perinephritis, perityphlitis, peri- 
metritis, etc., which characterize the different forms of circumscribed 
peritonitis. 

Perforative peritonitis may destroy life in a very short time ; but, if 
the perforation be preceded by adhesive inflammation, the course of the 
disease may be greatly prolonged, and may assume a very moderate 
degree of severity. When excited by a sudden perforation, like that 
which is produced by gastric or intestinal ulcer, the patient complains of a 
sudden, frightful pain, as if something had given way within the body. 
The symptoms of collapse are rapidly developed ; cold sweat covers the 
pallid skin ; the extremities become icy cold ; the abdominal wall is tense, 
and inordinately sensitive to the slightest touch ; life ends in unspeak- 
able torment in the course of a few hours. 

Less violent forms of the disease correspond closely with ordinary 
purulent peritonitis ; vomiting, pain, and the other symptoms of acute 
inflammation are manifested ; gas from the intestinal canal frequently 
enters the peritoneal cavity, and the abdomen is distended by the asso- 
ciation of gas and liquid in the peritoneal sac (Pneumo-peritonitis). 



■iOS diseases :j the liver, btc. 

Under such circumstances, the intestines are pressed backward a e - 
the spinal column, and their movements are no longer apparent through 
the abdominal wall. Agitation of the body produces a succession sound. 
that which is heard under similar circumstances in the pleural 
cavity, and the limits- between liquid and gas can be readily denion- 
ted by percuss:::.. 

Chronic pe i Circumscribed forms of chron: | eritonitis 

may be gradually developed without any characteristic symptoms, in 
connection with local diseases :f the various abdominal organs. The 
<iiffuse form of chronic peritonitis sometimes exists as a result of 
the acute form of the lisease, or it may occur as a complicati: 
tuberculosis or cancerous invasion of the peritoneum. It is sometimes 
developed in connection with scurvy or chronic inflammation of the 

rys. In certain cases a chronic serous peritonitis exists tha 
with difficulty (distinguished from ascites. 

Chronic peritonitis is characterized by a very moderate degree of 
pain, but the peritoneal cavity exhibits evidences of considerable -dis- 
tention with fluid, which renders rapid movement difficult and dis- 
tressing. Occasionally, patients are able, as in conespon ing asea :: 
chronic pleurisy, to continue the occupations of an active life in spite 
of their condition: but. under ordinary circumstances, the function ::' 
digestion and nutrition are seriously impaired. 

TLe duration of the disease : c very uncertain. Tuberculosis and 
cancerous disease lead to a fatal result. Deatl frequently follows - 
eonsequence of gradual wasting and exhaus:: 

Diagnosis. Acute peritonitis must be distinguished finom (1) ( - 
tr algid, which is characterized by a painful condition of the stomach 
that is frequently diminished by pressure, or by taking food. 

.'.-. which is marked by wandering pain, flatulence, and bor- 
borygmi. 3) From M :. which are accomr. 

Borders :-f the liver and kidney- >y un in the hepatic or renal 
territories, and by the appearance of calculi in the stools or in the urine. 
(4 Rheumatism of tht i malfmucles is characterized by a super- 
ficial location of the pain in the muscular layer of the abdominal wall. 
The differential diagn:- - etween peritonitis and ascites will be con- 
sidered in connection with that diseae 

PROGNOSIS. Every case of peritonitis is t s. Even after ap- 

parent recovery, the possibility of future difficulty by reason of adhe- 
- and intestinal incarceration or constriction must always be kept 
in mind. 

Treatment. The diet must be res I to liquids. The abdomen 

red with a warm poultice, or. if that cannot be tolerated, 
a layer of flannel, wrung out of hot water, may be laid upon the ab- 
dominal surf;. ed with oiled silk or thin rubber cloth. Half 
i:n of opium should be given every hour until the pupils become 
acted : after that, the interval may be lengthened : but under all 
circumstance-. 3\ ecially during the course of puerperal peritonitis, 
opium should be given in quantity sufficient to allay pain, and to 

ice the pulse below one hundi ts. If vomiting preve: 

exhibition by the mouth, hypodermic injections of morphine may be 



DISEASES OF THE PERITONEUM. 409 

employed. A constipated condition of the bowels may be relieved by 
the use of large injections of water. Severe pain at the outset of the 
disease may be reduced by the application of a number of leeches over 
the seat of greatest suffering. Excessive meteorism can be abated 
sometimes by the external and internal use of the oil of turpentine. 
Puncture of the intestinal coils with a fine trocar has sometimes given 
relief, but this operation is not without the danger of exciting a putrid 
peritonitis by the admission of feces into the peritoneal cavity. 
Sometimes the introduction of a long rectal tube beyond the sigmoid 
flexure affords opportunity for the escape of imprisoned gas. High 
fever requires the use of acetanilide and phenacetine in doses of five to 
fifteen grains as required. 

For information regarding the treatment of purulent peritonitis by 
laparotomy and washing out the peritoneal sac, the surgical text-books 
may be consulted. Chronic peritonitis requires a nutritious diet, and 
general treatment with iodide of potassium, iodide of iron, and external 
counter-irritation. If the effusion be of a serous character, it may be- 
come necessary to tap the peritoneal cavity. 

Peritoneal Dropsy — Ascites. 

Etiology. The term ascites signifies the accumulation of a liquid 
transudate within the peritoneal cavity. It is often observed as a 
local manifestation of general dropsy. As an independent transuda- 
tion, it is sometimes difficult to distinguish from the serous effusion of 
chronic peritonitis ; and, as a matter of fact, the limit between the two 
diseases is sometimes not very clearly defined. 

When peritoneal dropsy occurs independently of general oedema, it 
is the result either of an increased pressure within the portal vessels, 
or of diminished resistance on the part of their vascular walls. An 
increase of pressure attends all diseases by which the circulation of 
blood through the heart or through the liver is hindered ; hence it 
accompanies the majority of severe cardiac, pulmonary, and hepatic 
diseases. 

The resistance of the vascular walls appears to be diminished by all 
excessive discharges which reduce the albuminous constituents of the 
blood — e.g., chronic nephritis, chronic diarrhoea, protracted suppura- 
tions, hemorrhages, cancerous diseases, syphilis, etc. 

Ascites may occur at any age, but it is most frequently observed 
during the first half of adult life, when its causes are most commonly 
encountered. It has been observed, even before birth, to such an extent 
that the act of parturition was greatly impeded by the abnormal size of 
the foetal abdomen. In such cases, congenital malformations and 
maternal dropsy are often noted as concurrent events. 

Pathological Anatomy. The peritoneal cavity contains a large 
quantity of amber-colored liquid, which may be stained with bile pig- 
ment in cases of jaundice, or with blood in hemorrhagic diseases or 
when the abdominal cavity has been invaded by cancer or tuberculosis. 
Occasionally, crystals of cholesterine and flakes of endothelium may be 
discovered by the aid of the microscope. The reaction of the fluid is 



410 



DISEASES OF THE LIVER, ETC. 



almost always alkaline, and its specific gravity varies between 1004 
and 1014. Chemical analysis indicates the presence of the constituents 
of blood plasma, as might be expected from the source of the fluid. In 
certain cases of cancer, or tuberculosis, or chronic inflammation of the 
peritoneum, the liquid presents a milky appearance, which is caused 
by the presence of numerous cells that have undergone fatty degenera- 
tion and solution (Ascites adiposus). In rare cases, after rupture of 
the chyle ducts the ascitic fluid consists of chyle in a greater or less 
degree of purity (Ascites chylosus). 

In chronic eases of ascites the abdominal organs may undergo a cer- 
tain amount of atrophy from pressure, and the peritoneal membrane 
appears thickened and clouded as if its cellular structure had under- 
gone maceration. Usually the transudate is freely movable within the 
peritoneal cavity ; but, in rare cases, its movements are hindered by 
the existence of peritoneal adhesions. 

Symptoms. The amount of transudate within the peritoneal cavity 
must exceed thirty ounces before its presence can be readily detected. 
Any considerable accumulation is attended by a sensation of fulness 



F 


[G. 91. 


/ 

f 


r >, 


S 


? 


I 




/ 

1 

1 

\ 


( 

1 •' 


' 


.-- 



Fig. 92. 




Ascites. (Rush Medical College Clinic.) 



The shading indicates the position of the 
percussion-dulness in a case of ascites, while 
the patient is lying on the hack, the fluid 
falling to the low level in the flanks, and 
the umhilical region remaining clear. (FiH- 

LAYSON.j 



and tension within the abdomen ; as the cavity becomes distended, the 
movements of the diaphragm are impeded, and respiration becomes 
more shallow and difficult. The symptoms of subacute gastrointes- 
tinal catarrh are usually present, and frequent micturition follows the 
increase of presssure upon the bladder. The lower portion of the abdo- 
men becomes very prominent, and its upper portion follows suit as the 
liquid rises. (Fig. 91.) The cutaneous surface is pale, smooth, and 
shining. In severe cases, the abdominal wall is marked with purple 



DISEASES OF THE PERITONEUM. 411 

striae which indicate the lines of tension and partial rupture that involve 
the subcutaneous tissue. After evacuation of the peritoneal cavity by 
the operation of tapping, these striae assume a cicatricial appearance, 
like the lineae albicantes which indicate a previous pregnancy. The 
subcutaneous veins also present an appearance of distention, and their 
superficial anastomoses become very apparent, especially when the portal 
circulation is obstructed. The navel frequently becomes very promi- 
nent and distended with fluid. 

Fluctuation within the abdominal cavity may be readily demonstrated 
by placing the palm of one hand upon the lateral surface of the belly 
near the upper limit of the transuded fluid, and with the finger-tips of 
the other hand tapping lightly upon the opposite side of the body. A 
distinct impulse can be thus distinguished through the medium of the 
interposed liquid. Percussion readily indicates the limits of the tran- 
sudation, though its upper surface does not present an absolute level, 
on account of the ascent of the liquid between the folds of the superin- 
cumbent intestines. When the patient lies flat upon the back, the 
region of dulness occupies the lateral and inferior portions of the abdo- 
men, while the umbilical region is tympanitic by reason of its occupa- 
tion by the gaseous intestines. (Fig. 92.) If the intestinal canal be 
free from fecal contents, the region of the caecum and of the descending 
colon will emit a tympanitic sound on percussion, even though the 
adjacent regions are occupied by the dropsical fluid. Obviously, the 
area of dulness will vary with every change in position, unless the tran- 
sudate is encapsulated by peritoneal adhesions. 

The duration of the disease may cover many months or years. Re- 
lapses are not unfrequent. Death usually results from the underlying 
causes of dropsy ; or it may be produced by asphyxia, in consequence 
of compression of the thoracic organs. 

Diagnosis. The diagnosis of ascites is established by two symptoms : 
fluctuation within the abdomen, and the presence of dulness that is sub- 
ject to variation through changes of position. If any doubt exists with 
regard to the character of the fluid, it can be readily removed by 
an exploratory puncture. If the specific gravity of the liquid thus 
obtained does not exceed 1015, it is a dropsical transudation, and not a 
peritoneal exudation, by which the patient is distressed. 

It may be, sometimes, difficult to differentiate ascites from an ovarian 
cyst (Fig. 93), but the differential diagnosis will be assisted by atten- 
tion to the following points : 

Ascites. Ovarian Cysts. 

In the dorsal position the belly is flat- The abdomen remains prominent. 

tened. 

The navel assumes hernial prominence. The navel remains unchanged, or it is 

depressed. 

Abdominal distention is uniform. Distention is locally circumscribed. 

In the dorsal position, dulness on per- Dulness occupies the anterior portion of 

cussion occupies the lateral portions the abdomen, while the lateral por- 

of the abdomen tions arc tympanitic. 

The upper limits of dulness present an The upper limit is uniform. 

undulating contour. 

Variations in position are accompanied There is no corresponding change. 

by corresponding variations of the 

percussion note. 



412 



DISEASES OF THE LIVER, ETC. 



Ascites 

Fluctuation occupies the whole width of 

the abdomen. 
The uterus is often very movable, and 

the vaginal walls are depressed by the 

superincumbent fluid. 
The specific gravity of the dropsical 

fluid is less than 1014, and the liquid 

is clear and transparent. 
Microscopical examination reveals the 

presence of endothelial cells. 



Ovarian Cysts. 

Fluctuation is restricted by the limits of 
the tumor. 

The uterus is generally elevated or 
pushed aside, and the vaginal walls 
are not depressed. 

Specific gravity between 1018 and 1024, 
and the fluid exhibits a thick and tur- 
bid character. 

Cylindrical cells are present. 



Fig. 93. 




Prognosis and Treatment. The prognosis in ascites depends upon 
its cause, and the treatment must be guided by similar considerations. 

Cathartics, diuretics, and diaphoretics 
must be chosen in accordance with 
the directions given in previous chap- 
ters. When the liquid transudate 
cannot be restrained within tolerable 
limits, it is advisable to puncture the 
abdominal wall, and to evacuate the 
fluid. This should not be looked upon 
as a last resort, since the comfort of 
the patient may be thus greatly in- 
creased, and the chances of ultimate 
recovery are correspondingly im- 
proved, for in many cases repeated 
puncture has finally led to permanent 
disappearance of the dropsy. The 
operation may be readily performed 
by the aid of a trocar which has been 
thoroughly cleansed in a five per cent, 
solution of carbolic acid. The patient 
may remain in a recumbent position, 
or, if possible, should sit upright in a 
convenient chair. The trocar should 
be quickly plunged through the abdo- 
minal wall, midway between the umbili- 
cus and the pubes, having previously 
made sure that the bladder is empty. Many surgeons prefer a trocar 
that is provided with a stopcock, which can be connected with a rubber 
tube after the stylet has been withdrawn ; through this the fluid flows 
readily into any convenient receptacle. Sometimes a fold of intestine 
may obstruct the entrance of the trocar, necessitating the introduction 
of a sound by which the intruding fold can be pushed aside. The 
evacuation of the abdomen may be assisted by passing two towels around 
the body, one above and the other below the trocar, while their ends 
are held by an assistant who stands behind the patient, and gradually 
draws them together as the abdominal swelling subsides. If faintness 
result from the development of cerebral anaemia through excessively rapid 
discharge of the fluid, the operation may be temporarily suspended ; 
after the administration of stimulants, or after a short delay, the re- 



Position of an ovarian tumor of the 
right side, in various stages of enlarge- 
ment. The shading indicates the per- 
cussion- dulness in ovarian dropsy of 
moderate extent : the umbilical region 
is dull, from the presence of fluid, and 
the flanks remain clear. The outer 
circle shows a further extent to which 
the dulness may reach 
dropsy. (Bright.) 



in ovarian 



DISEASES OF THE SPLEEN. 413 

maining fluid may be evacuated. After the trocar has been withdrawn, 
the wound should be closed by the passage of a needle through its walls, 
and the application of a crucial ligature. 

Good effects have sometimes been observed after faradization of the 
abdominal walls with a strong current. Copious diuresis is thus pro- 
duced, which sometimes relieves the dropsical swelling. 

Peritoneal Cancer — Carcinoma Peritonei. 

Peritoneal cancer is almost invariably a secondary development from 
a malignant disease whose primary seat is in other organs of the body. 
The tumors sometimes attain great size, but in certain cases they appear 
in the form of minute nodules which resemble miliary tuberculosis. 
The disease is usually accompanied by peritonitis or ascites, and the 
exudation is, frequently, of a hemorrhagic character. The prognosis 
is unfavorable, and the treatment is purely symptomatic. 



CHAPTER VI. 

DISEASES OF THE SPLEEN. 

Acute Enlargement of the Spleen. 

Etiology. Rapid increase in the size of the spleen is frequently 
observed in connection with various diseases of which it forms one of 
the symptoms. 

Traumatic enlargement of the spleen is not often observed. It is 
caused by injuries of the organ which produce dilatation of its blood- 
vessels, together with extravasation of blood, and increase in the size 
and number of the cells in the splenic pulp. 

Acute embolic enlargement of the spleen is produced by embolic ob- 
struction of its arteries. This accident usually follows the existence of 
vegetations upon the valves of the heart, which break loose and find 
their way into the general circulation. 

The spleen sometimes becomes considerably enlarged by reason of 
obstruction in the course of the circulation of the blood, either as a 
consequence of disease in the heart, lungs, or liver. Stagnation of the 
blood in the portal vein is the most common cause of splenic en- 
largement. This may be produced either by cirrhosis of the liver, or 
by compression of the portal vein itself through the growth of tumors 
in its vicinity, or by inflammatory processes in the venous walls 
(pylephlebitis). 

In the majority of cases of acute splenic enlargement the cause is 
connected with an infective process. It is therefore more or less con- 
spicuous during the course of all infective diseases. The amount of en- 
largement is not dependent upon the severity of the disease, nor does 



414 DISEASES OF THE LIVER, ETC. 

its maximum always coincide with the height of the fever. Sometimes 
the existence of splenic enlargement precedes the other symptoms of 
infection ; and in other cases it persists for a considerable time after 
their subsidence. It has been remarked that after typhoid fever, 
relapses may be feared so long as the spleen remains enlarged. 

It is probable that the swelling of the spleen which accompanies in- 
fective diseases is due to the local presence and activity of the micro- 
organisms which invade the system, either as primary infective agents, 
or as secondary followers of the original contagion. All minute par- 
ticles of foreign matter that are introduced into the blood tend to find 
lodgment in the cells of the spleen, so that it is not difficult to com- 
prehend the possibility of irritation and consequent proliferation of the 
splenic cells when they have been thus excited by an invasion of poi- 
sonous microphytes. 

Pathological Anatomy. Acute enlargement of the spleen may 
attain to five or six times the normal size of the organ. When it is 
caused by traumatism, the evidence of injury may be discovered in the 
adjacent tissues and organs. When produced by embolic obstruction 
of the arterial branches, the characteristic pyramidal infarcts can be 
easily recognized in the substance of the spleen. Enlargement of the 
organ that is dependent upon general obstruction of the blood circulation 
is indicated by excessive distention of the bloodvessels, and by the 
existence of portal stagnation, or disease in the heart or respiratory 
organs. When enlargement is caused by an infective process, the 
organ is smooth and rounded ; its capsule is transparent and tense. 
The splenic pulp is soft and friable, though tolerably firm. The splenic 
cells are enlarged, and their nuclei are multiplied and sometimes fatty. 
The vascular walls are infiltrated with round cells and blood corpuscles. 

Symptoms and Diagnosis. Enlargement of the spleen may occur 
without any subjective sensations, but sometimes there is complaint of 
tension and pain in the splenic region, extending even to the left 
shoulder and into the lower extremity. This pain is sometimes in- 
creased when the patient lies upon one side or the other. Pressure 
produced by coughing or straining may also occasion suffering. If the 
abdominal wall is very thin, a large tumor may sometimes become per- 
ceptible as a projection from beneath the lower ribs on the left side. 
The tumor may under such circumstances be distinctly recognized by 
palpation, and it may be felt to change its position in unison with the 
respiratory movements. Sometimes the notch upon its anterior margin 
can be felt, when the organ protrudes considerably toward the median 
line of the body. When the spleen is considerably enlarged, the change 
of volume may be recognized by percussion, though it is necessary to 
avoid the sources of error which may arise from the presence of solid 
masses in the stomach or colon. Excessive distention of the bowels 
with gas may serve to obscure the evidence derived from percussion. 
Occasionally an audible murmur can be heard on auscultation over the 
spleen. This is caused by the movement of blood in the enlarged 
vessels of the tumor, and it somewhat resembles the placental murmur 
that is audible during pregnancy. 



DISEASES OF THE SPLEEN 



415 



Prognosis and Treatment. The prognosis depends upon the 
nature of the cause of splenic enlargement. Rupture of the spleen 
occurs so seldom that it need not be taken into consideration. The 
disease rarely requires any special treatment other than is indicated for 
the causal disease. Severe pain requires the use of morphine. 

Chronic Enlargement of the Spleen. 

Etiology. Chronic enlargement of the spleen may result from its 
acute enlargement, but sometimes it is gradually developed as a chronic 
disease. A very frequent cause is found in malaria, which need not 
necessarily excite the symptoms of acute fever, but through the cachexia 
which chronic infection produces, the spleen is gradually enlarged. 

Fig. 94. 




Various degrees of enlargement of the spleen. The lines indicative of splenic enlarge- 
ment are copied exactly from Weil, but the percussion limits of the heart and liver have 
been somewhat modified. (Finlayson.) 



Splenic tumor also accompanies leuknemia, pseudo-leuksemia, amy- 
loid degeneration, cancerous growths, tuberculosis, syphilis, rickets, 
and scrofula. It is sometimes congenital, especially in syphilitic cases, 
though otherwise rarely observed among children and old people. 



416 DISEASES OF THE LIVER, ETC. 

Pathological Anatomy. Chronic enlargement of the spleen may 
attain to twenty times its normal size, or even larger. In some cases 
it occupies the greater part of the abdomen. The capsule becomes 
thickened, and the anterior border of the organ exhibits one or more 
deep notches which correspond to the normal indentation of its margin. 
Sometimes local peritonitis and consequent adhesions exist. If neo- 
plasms or hydatid cysts have developed in the spleen, they present 
themselves as rounded prominences. The existence of embolism is 
indicated by the presence of the characteristic infarcts. In certain 
cases the enlargement of the organ is chiefly caused by excessive pro- 
liferation of the splenic cells ; but in that form of the tumor which is 
produced by blood stagnation the connective tissue chiefly is increased. 
Malarial poisoning causes a deposit of great quantities of blood piginent 
in the spleen. 

Symptoms and Diagnosis. The symptoms that have been already 
described in the previous chapter are present in connection with en- 
largement of the spleen ; but, in addition, the symptoms of a chronic 
cachexia are also developed. The patient is pale, and the skin exhibits 
an earthy or chlorotic hue. Palpitation and shortness of breath are 
common occurrences. Hemorrhage into the skin and from the mucous 
membranes frequently takes place ; and ancemic murmurs are audible 
over the heart and large vessels. In many cases oedema develops 
along with the progressive cachexia. 

Prognosis. Since the prognosis is conditioned by the cause of the 
tumor, an unfavorable prospect is very common. The duration of 
the disease may be prolonged for a number of years before the patient 
dies, worn out by the effects of compression and cachexia. 

Treatment. The treatment of splenic tumor must be guided by 
causal indications. Syphilitic enlargements rapidly yield to iodide of 
potassium. Hydatid tumors require surgical treatment. Malarial 
spleens are benefited by quinine and arsenic, especially if the patient 
can be removed to a healthy locality. The various causes of anaemia 
require the administration of iron and other remedies that are useful in 
specific forms of impoverishment of the blood. The external application 
of cold and of electricity is sometimes useful. Various counter-irritants 
may be applied over the spleen with benefit in those cases that depend 
upon curable disease. The tumor has been removed with some degree 
of success when its enlargement and pressure have threatened serious 
interference with the functions of the heart and lungs. 

Embolic Infarction of the Spleen. 

In about one-half of the cases of embolism from valvular diseases of 
the heart the seat of obstruction is located in the spleen. The portion 
of the organ from which the blood-supply is cut off by occlusion of an 
arterial branch presents a pyramidal form, with its base at the periphery 
of the organ, and its apex at the point of obstruction near the hilum of 
the spleen. At first the infarct appears dark-red and hepatized, but 
gradually the color fades from the apex toward the base of the pyramid. 
The tissue cells within the obstructed territory undergo granular degen- 



DISEASES OF THE SPLEEN. 417 

eration and caseation, and finally constitute a relatively dry and crum- 
bling mass. Sometimes calcification terminates the process, but in certain 
cases the dead tissues are gradually absorbed, leaving only a pigmented 
scar in their place. In this way the spleen may become considerably 
deformed by cicatricial contraction. If the embolic fragment is charged 
with septic infection, an abscess may be produced in place of the ordi- 
nary infarct 

The occurrence of splenic embolism may be suspected when valvular 
disease of the heart exists, and the patient suddenly complains of chills, 
vomiting, and pain in the splenic region, followed by an enlargement 
of the spleen itself. The only treatment that is possible is of an expec- 
tant character. Pain must be relieved by hypodermic injections of mor- 
phine ; and the local application of cold or heat may be conducted in 
accordance with the feelings of the patient. 

Perisplenitis. 

Perisplenitis has been already described under the head of local peri- 
tonitis. It is caused either by local injuries, or as a result of inflam- 
mation of the spleen itself in connection with various diseases and en- 
largements to which the organ is liable. The principal symptoms are 
pain, accompanied by a certain amount of fever, and evidences of local 
peritonitis. The treatment is the same as that which has been recom- 
mended for the control of circumscribed peritonitis. 

Inflammation of the Spleen — Splenitis. 

Etiology. Primary inflammation of the spleen is rarely observed, 
except as a consequence of violent local injury of the organ. The 
disease usually occurs as a secondary consequence of embolism, especi- 
ally after the intrusion of septic emboli into the branches of the splenic 
artery. For this reason abscesses sometimes follow the infective dis- 
eases. In certain cases splenitis is the result of inflammation propa- 
gated from neighboring organs. In this way ulceration and inflamma- 
tion of the stomach, perinephritis, and gangrene of the lungs have been 
known to originate the disease. 

Pathological Anatomy. The size of a splenic abscess may vary 
from that of a pea to that of a hen's egg. Sometimes, however, the 
entire substance of the organ breaks down, and the abscess is limited 
only by the splenic capsule. In this way abscesses containing many 
quarts of pus are developed. Under such circumstances the danger of 
rupture and of consequent peritonitis is very great. 

Symptoms and Diagnosis. The symptoms of splenic abscess are 
often very obscure, so that its recognition is sometimes impossible dur- 
ing life. In other cases hectic fever and the usual symptoms of suppura- 
tion may exist without any positive indication of their connection with 
the spleen. A positive diagnosis is only possible when a fluctuating 
tumor can be discovered in the splenic region, or when a sudden 
discharge of pus into a neighboring cavity or passage is followed by the 
subsidence of such a tumor. Sometimes the pus burrows its way 

27 



118 DISEASES OF THE LIVER. ETC. 

through the external parts, and reaches the surface at a considerable 
distance from the site of the abscess. In all such cases a fatal result 
is frequently determined by peritonitis or by general pya?mia. conse- 
quently the prognosis is exceedingly alarming, and the treat 
requires the efficient intervention of skilful surgery. 

Amyloid Degeneration of the Spleen. 

Etiology. The causes of ar oration of the spleen are the 

same that have been described as the causes of such degeneration in 
the liver, kidneys, and other organs of the body. The spleen appears 
to be more liable to amyloid degeneration than any other organ: and it 
is here that the process commences in the majority of cases. 

Pathological Anatomy. The early stages of amyloid degeneration 
can be recognized only by the aid of the microscope, but when the 
disease is considerably advanced it may be easily recognized in two 
forms, the sago spleen, and diffuse amyloid degeneration. 

The term sago spleen is applied to that form of degeneration which 
principally involves the Malpighian bodies. On section of the org 
these appear in the form of pearly gray translucent masses, like grains 
of boiled sago. The characteristic reactions with iodine are very 
spicuous. 

Diffuse amyloid degeneration invades the whole organ, which is 
greatly enlarged and presents a firm and resistant mass, in color and 
consistence resembling smoked ham. It is by no means certain that 
this form represents an advanced stage of the disease, since the sage 
spleen is often observed in old cases of amyloid disease. 

With the aid of the microscope, the amyloid process which com- 
mences in the capillary walls may be traced into the connective tissue. 
Opinions are divided with regard to the participation of the splenic cells 
in the disease. 

Symptoms and Diagnosis. The early stage of the disease cannot be 
recognized, but when the conditions of amyloid degeneration are 
ent. an enlargement of the spleen may be reasonably referred to that 
cause, especially when other organs of the body give evidence of degen- 
eration. 

Prognosis and Treatment. After the early stages of the dia s 
have been traversed there is little hope of recovery. The tre<>' 
consists chiefly in the employment of preparations of iodine, and the 
iodide of iron. Mineral waters that contain these substances are con- 
sidered beneficial. 



Cancer of the Spleen — Carcinoma Lienis. 

of the spleen rarely occurs as a primary disease. It usually 
follows the development of carcinoma in the liver, stomach, or abdominal 
lymph glands. It usually assumes the medullary form. Sometimes 
the new growth is deeply pigmented. Only when the spleen is greatly 
enlarged is the diagnosis possible, or when a splenic turn-. - - iated 
with evidence of cancerous growth in other organs. Sarcomatous 



DISEASES OF THE SPLEEN. 419 

tumors are not uncommon in the spleen ; and occasionally other forms of 
tumor have been discovered in the organ. 

Rupture of the Spleen. 

Rupture of the spleen is sometimes caused by direct violence, and 
occasionally it results from enlargement that progresses too rapidly to 
be restrained by the relatively unyielding capsule. Under such circum- 
stances a sudden movement or compression of the tumor occasions its 
rupture. This sometimes occurs as a consequence of the acute enlarge- 
ment of the spleen that is connected with infective diseases. The 
accident is followed by the symptoms of internal hemorrhage, together 
with pain in the splenic region. Death usually follows in a short time, 
though occasionally recovery has been witnessed. If life be prolonged 
for a few days the symptoms of peritonitis are added to those of hemor- 
rhage, and the appearances after death correspond to the symptoms 
that were observed during life. 

Wandering Spleen — Lien Mobile. 

In certain cases the attachments of the spleen become relaxed to such 
a degree that it descends by the force of gravity into the left iliac 
fossa, or may be found upon the opposite side of the body when the 
patient lies upon the right side. It sometimes falls into the cavity of 
the pelvis, or may be discovered in any part of the abdomen according 
to the position temporarily assumed by the patient. Under such cir- 
cumstances it may be difficult to distinguish the splenic mass from a 
wandering kidney, from enlarged lymphatic glands, from ovarian 
tumors, or even from pregnancy itself. A common cause of this con- 
dition exists in the enlargement of the spleen that has been previously 
described. Sometimes the splenic pedicle becomes twisted, and the 
vascular supply of the organ may be thus cut off, so that the tumor 
degenerates and becomes atrophied. 

In certain cases there is no complaint of subjective symptoms, but 
many patients complain of pain and dragging sensations, accompanied 
by a disposition to defecation or micturition, caused by local pressure 
upon the pelvic organs. Sometimes various perversions of sensation, 
and paresis in the lower extremities, may be referred to the effects of 
pressure upon the large nerves in the lower part of the body. The 
diagnosis is comparatively easy when the abdominal walls are thin, so 
that the outline of the spleen can be accurately defined. A recognition 
of the characteristic notch in its anterior border greatly assists the 
diagnosis. 

A congenital transposition of the liver and of the spleen has been 
occasionally observed. The spleen may also be very considerably dis- 
placed by various deformities and diseases that involve the thorax, and 
occasion depression or elevation of the diaphragm. 

The treatment of wandering spleen by medicinal agents is very unsat- 
isfactory. Bandages and trusses are sometimes moderately successful, 
but in troublesome cases the extirpation of the organ may become 
necessary. 



PART V. 

DISEASES OF THE ORGANS OF 
RESPIRATION. 



DISEASES OF THE RESPIRATORY APPARATUS. 
CHAPTER I. 

DISEASES OF THE NASAL PASSAGES. 

Nasal Catarrh — Coryza — Rhinitis Catarrhalis. 

Etiology. Nasal catarrh is a common consequence of exposure to 
damp and cold air. Unilateral chilling of the body is more dangerous 
than equal refrigeration of all portions, hence the risk that is incurred 
by exposure to drafts of air when overheated. An exact discussion of 
the manner in which inflammation is thus originated would occupy too 
much space ; it will be sufficient to direct attention to the part that is 
taken by the ordinary microbes of inflammation when the resistance of 
the tissues is diminished by cold. In like manner local causes may 
operate to excite inflammation of the nasal membranes. Witness the 
effects of wounds, injuries, inhalation of irritating gases, hot air, dust, 
and the pollen of certain plants. Powdered ipecacuanha cannot be 
inhaled by certain persons without the production of an acute coryza. 
Iodide of potassium, digitalis, and other substances occasionally produce 
the same result. The arthritic constitution, the occurrence of menstrua- 
tion, and mental excitement, sometimes act as predisposing causes of 
the disease. Direct infection of the nasal mucous membrane with 
gonorrhoeal pus, and other infective discharges, is not unknown. 

Symptoms. Nasal catarrh may exist either as an acute disease, or 
as a chronic malady. 

Acute coryza. The attack is generally introduced with more or less 
chilliness, headache, feeling of weakness, pain in the back and limbs, 
with loss of appetite, and other phenomena of a moderate fever. Nervous 
and excitable children may exhibit symptoms of delirium ; and con- 
vulsions sometimes occur, perhaps as a consequence of the facility with 
which chills, in such constitutions, are replaced by convulsions. In the 
course of a few hours a sensation of dryness and of prickling is 



422 DISEASES OF THE ORGANS OF RESPIRATION. 

experienced in the nasal passages. There is obstruction to easy res- 
piration through the nose, and the voice acquires a nasal tone. The 
senses of smell and of taste are suppressed, and there is an inclination 
to sneezing. 

These symptoms are soon followed by the appearance of a thin, 
watery liquid, with a saline taste, which distils from the mucous mem- 
brane of the nose : the saline character of the secretion is chiefly due 
to the presence of chloride of ammonium, which acts as an irritant to 
the cutaneous surface of the upper lip over which it flows. A few 
epithelial cells and pus corpuscles alone serve to cloud the transparency 
of the discharge, but in the course of a few days it becomes turbid with 
pus corpuscles, and assumes a greenish and albuminous appearance, 
constituting a muco-purulent discharge. 

The inflammation may extend to the lining of the frontal sinuses : 
and. through the tear ducts, it may reach the conjunctiva?, producing all 
the local symptoms of conjunctivitis. In like manner it may invade the 
cavity of the antrum Highmori. producing sensations of fulness and 
pain, with a flow of liquid into the nasal passages when the head is laid 
upon one s: : .r :. :he other. The Eustachian tube may also furnish an 
avenue for the extension of inflammation into the cavity of the middle 
ear. with consequent pain, deafness, and abnormal sounds in the ear. 
TThen the posterior nares and pharynx are reached, sensations of heat 
and difficult deglutiti : experienced. The disease may be propa- 

gated still further, invading the larynx and trachea, or the alimentary 
canal. 

The duration of the symptoms is usually about a week, though some- 
times it may become merged into the chronic form of nasal catarrh. 

Nursing infants sometimes suffer from an acute inflammation of the 
nasal membranes. The congenital narrowness of those passages renders 
such an attack more dangerous than at a later period of time, because 
of the difficulty that attends the act of suction when the child c 

the through the nose. Artificial feeding may become necessary in 
severe cases. 

Chronic nasal catarrh. Chronic nasal catarrh sometimes forms the 
sequel of an acute attack, or it may be the direct consequence of chronic 
infective disease, such as tuberculosis or syphilis. It sometimes forms 
one of the manifestations of a universal and chronic tendency to 
catarrhal inflammation, involving all the mucous membranes of the 
body. 

The prominent symptoms are derive 1 from obstruction of the nasal 

— ges, rendering it necessary for the patient to breathe with the 
mouth partly open. Everyone is familiar with the peculiar express 

red l»y such a d of the respiratory p - ges, Tue senses 

of smell and taste are more or less impaired : the voice acquires a i - 
tone, and there is a constant muco-purulent discharge, which sometimes 
is exceedingly cop: is, astft _ : is termed rhinorrhoea. Tlie 

mucous membranes of the nose are swelled, dark red, an 1 covered with 
a muco-purulent secretion that forms obstructive crusts by which the 
- g - are filled. These sometimes un _ is iegenera- 

tion. and are transformed into the BO-called rh> 



DISEASES OF THE NASAL PASSAGES. 423 

In certain cases the inflamed surface is invaded by a specific bacillus 
(bacillus foetidus ozsenae), which by its activity causes the production of 
an intolerable odor in the nasal secretion. This variety of inflammation 
is known as ozcena. 

The mucous membrane sometimes becomes ulcerated. The necrotic 
process may extend to the cartilaginous and bony portions of the nose, 
which, when invaded, give occasion for the formation of offensive dis- 
charges, constituting a special variety of ozsena, known as ozcena 
ulcerosa. 

Chronic inflammation may affect the frontal sinuses and the antrum 
of Highmore ; the orifice of this last cavity is sometimes obstructed so 
that the products of inflammation are retained and cause painful and 
deleterious pressure upon its walls. 

The disease is more distressing than dangerous. If cured it is liable 
to relapses, and it may excite reflex disturbances in other portions of 
the respiratory tracts. 

Treatment. It is desirable, in all cases that are characterized by 
a proclivity to catarrhal inflammation, that measures should be adopted 
for improvement of the general health, and an increase of the resistance 
to cold. For this purpose, daily exercise in the open air, cold sponge 
baths, and active exercise, with sufficient clothing, and the avoidance of 
exposure to the exciting causes of disease, must be advised. Special 
predispositions and chronic infective processes, such as are connected 
with tuberculosis and syphilis, require appropriate treatment. 

Acute nasal catarrh seldom requires anything more than a hot foot- 
bath, and a bowl of hot mint tea before going to bed. Ten grains of 
Dover's powder administered at the same time will relieve pain and 
promote perspiration, thus frequently aborting the attack. A grain of 
quinine three times a day may be taken, subsequently, for a week, with 
advantage. If the local symptoms are attended with considerable irri- 
tation, inhalation of the vapor of warm water will give great relief. 
This may be easily accomplished by filling with warm water a narrow- 
necked jug or pitcher, which is held near the face, while a large towel 
is thrown over the head, to retain the vapor. A one per cent, solution 
of common salt, or of chloride of ammonium, may be inhaled from an 
ordinary spray-producing apparatus. Temporary relief may also be 
obtained by inhaling air that is charged with the vapor of ammonia and 
carbolic acid (liquor ammonite, acid, carbolici, aa 5 parts; alcohol, 15 
parts ; distilled water, 16 parts). A few drops of this, sprinkled upon 
thick bibulous paper, may be inhaled every two hours. Care should 
be taken to keep the eyelids closed during the operation. 

The use of vaseline, or other lubricating substances, will diminish the 
tendency to irritation of the upper lip and nasal orifices. Chronic 
nasal catarrh, in addition to the general measures that are requisite for 
the improvement of the health, requires treatment with nasal douches 
and medicated snuffs. A douche with a one per cent, solution of car 
bolic acid, or, as an astringent, a one per cent, dilution of liquor aluminii 
acetici, may be employed three or four times a day. It should be fol- 
lowed by a pinch of snuff composed of three parts of calomel and five 
parts of powdered alum. The nasal douche should be also employed, 



424 DISEASES OF THE ORGANS OF RESPIRATION. 

instead of the ordinary irrigating apparatus, which is liable to produce 
injury of the auditory apparatus by forcing liquids through the Eus- 
tachian tube. A simple one per cent, solution of common salt, used 
with the nasal douche, forms the best means of removing crusts that are 
formed within the nose. For the cure of ozaena, two drachms of a one 
per cent, solution of permanganate of potassium may be added to a 
pint of tepid water, for use with the nasal douche. Other antiseptic 
solutions may be employed in the same way ; iodide of potassium must 
be given in cases of a syphilitic character. Ulcerated surfaces may 
require the topical application of nitrate of silver. For fuller details, 
the student is referred to special treatises upon the subject. 

Hay Fever — Catarrhus iEstivns. 

Etiology. Say fever occurs in two forms : as a catarrhal inflam- 
mation of the conjunctiva and respiratory passages : and as a special 
variety of asthma. It occurs more frequently among men than among 
women, and is most commonly experienced between the fifteenth and 
thirtieth years of life. It attacks persons of a highly organized and 
nervous constitution, and is almost unknown among the laboring 
classes. 

The disease occurs during the summer, and disappears with the 
return of cold weather. It recurs every year, and, generally, reappears 
at a definite time for each patient. The commencement of the attack 
usually coincides with the blossoming of certain plants, the pollen of 
which is irritating to the mucous membranes of those who are the vic- 
tims of this idiosyncrasy. The presence of pollen grains has often been 
demonstrated in the nasal secretion of hay fever, and their experimental 
introduction into the nasal passages has resulted in the artificial pro- 
duction of the disease. 

Symptoms. The symptoms of hay fever frequently follow imme- 
diately after exposure to the causes of the disease. A walk in the 
fields, or a change in the direction of the wind, bringing to the mucous 
membranes air that is charged with irritating particles, often excites an 
attack of sneezing, with uncomfortable sensations in the nose, followed 
by the appearance of abundant secretion, and swelling of the mucous 
membranes ; the eyes become red and watery ; the eyelids swell and 
become painful ; similar conditions manifest themselves in the thorax, 
and may invade the larynx and trachea ; slight febrile symptoms are 
sometimes present at the commencement of the disorder, and a feeling 
of discomfort persists throughout its entire course. Sometimes the 
nose becomes considerably swelled and reddened ; erythematous erup- 
tions occasionally appear upon the face, or upon other parts of the 
body. When the disease assumes an asthmatic character, the symptoms 
correspond with those of ordinary bronchial asthma. 

Hay fever is never fatal, unless it may chance to occur in connection 
with other diseases which have completely undermined the vigor of the 
constitution. 

Treatment. Of the greatest importance is the prophylactic treat- 
ment and the employment of measures for the improvement of the 



DISEASES OF THE LARYNX. 425 

general health. Galvano-caustic treatment of the tumefied membranes, 
snuffs, and douches, have all been employed with comparatively little 
success. Iron, quinine, arsenic, and strychnine are useful as general 
tonics and roborants ; for the same purpose electricity and Turkish 
baths have been employed with some degree of success. A solution of 
quinine (1 part to 740) was highly recommended, for irrgiation of the 
nasal passages, by the celebrated scientist Helm hoi tz, who was himself 
a victim of the disease. Recently it has been advised to make local 
applications of a ten per cent, solution of cocaine to the inflamed 
mucous membranes ; this gives temporary relief, but must be used with 
considerable caution for fear of establishing the cocaine habit. 

The only certain method of relief lies in avoidance of the causes of 
hay fever. The patient must withdraw from such parts of the country 
as lie under cultivation, and must retire to the northern wilds of the 
White Mountains, or the Adirondack region, or the vicinity of the lakes 
in Northern Michigan, Wisconsin, and Minnesota. There he must 
remain until the first frosts of autumn destroy the polleniferous plants 
that fill the air with irritating particles. In this way only can com- 
fort be secured during the summer months by those who possess the 
unfortunate predisposition to hay fever. 



CHAPTER II. 

DISEASES OF THE LARYNX. 

Catarrhal Inflammation of the Larynx — Laryngitis Catarrhalis. 

Etiology. Laryngeal catarrh is observed more frequently among 
men than among women, between the twentieth and fortieth years of 
life. It prevails in cold, damp climates, and is common during the 
spring and fall of the year, when the weather is most variable. Deli- 
cately constituted individuals, especially if they perspire easily and are 
predisposed to rheumatic affections, are very liable to catarrhal inflam- 
mations which sometimes affect one and sometimes another portion of 
the mucous surfaces of the body. The causes of such local predispo- 
sitions are unknown. In certain cases, however, the susceptibility of 
the laryngeal mucous membrane is evidently dependent upon the occu- 
pation of the individual. Witness the frequency of laryngitis among 
those who inhale irritating vapors and gases, or are exposed to an 
atmosphere filled with dust. 

Misuse of the vocal organs, such as is involved in public speaking, 
singing, shouting, etc., not unfrequently excites an attack of laryn- 
gitis. The infective diseases, especially those that invade the mucous 
membranes, and certain chronic disorders of the kidneys and liver, 
together with impoverishment of the blood from any cause, operate as 
predisposing causes of laryngitis. It may also accompany disturbances 



426 DISEASES OF THE ORGANS OF RESPIRATION. 

of the circulation in the course of cardiac diseases, and it accompanies 
the development of tumors and ulcerative processes in the neighborhood 

of the larynx. 

Symptoms. The disease may occur either as an acute or as a chronic 
catarrh of the larynx. The acute form usually commences with a 
moderate degree offerer, like that which ushers in an ordinary coryza. 
The local symptoms, however, are experienced within the throat, and 
consist of a sensation of irritation and inclination to cough. There is 
a feeling of tenderness in the region of the larynx, with pain upon 
swallowing ; sometimes external pressure over the larynx is painful. 

The cough is at first dry and harsh ; presently it is accompanied by 
the expectoration of a thin, transparent, slimy liquid that contains a 
few epithelial cells ; gradually it becomes charged with round cells and 
pus corpuscles, and assumes a muco-purulent character : sometimes the 
sputa exhibit streaks of blood which indicate a considerable degree of 
severity in the inflammatory process. 

The voice becomes hoarse, weak, and inclined to break. In severe 
cases it is reduced to a mere whisper as a consequence of local 
swelling that interferes with the movements of the vocal cords. Laryn- 
goscopy examination discovers a brightly reddened and tumefied con- 
dition of the mucous membrane lining the larynx. The minute blood- 
vessels are dilated, and the surface of the membrane is covered with the 
products of exudation, which accumulate until they are removed by the 
act of coughing. Sometimes minute hemorrhagic points are visible. 

In many cases the muscles of the larynx become temporarily paretic, 
or completely paralyzed, as a consequence of inflammation of their sub- 
stance. The respiration is impeded, under such circumstances, so that 
death may occur, with symptoms of asphyxia. 

Among young children of a nervous temperament and delicate organi- 
zation, acute laryngitis not unfrequently occurs with the sudden develop- 
ment of symptoms indicating laryngeal obstruction. The disease 
commences abruptly in the night, after several hours of quiet sleep, 
when the patient suddenly awakes and starts up in an agony of suffoca- 
tion interrupted by paroxysms of a hoarse, barking cough : febrile 
symptoms are often quite prominent, the face is flushed, the eyes are 
suffused, respiration is hurried and stridulous. with great difficulty in 
the act of inspiration, and retraction of the lateral walls of the thorax. 
The attack may continue for many minutes, or for a few hours, when it 
terminates spontaneously, unless arrested by the action of an emetic, or 
other anti-spasmodic remedy. Such cases, in their superficial features, 
bear a close resemblance to croup, or laryngeal diphtheria, hence the 
name false croup, by which they are frequently known. With the 
approach of morning, the urgent character of the symptoms disappears : 
and during the day. the patient may exhibit only the ordinary phe- 
nomena of subacute laryngeal catarrh ; but the spasmodic paroxysm is 
liable to be renewed, though with diminished severity, for a number of 
successive nights. 

The causes of false croup, or laryngismus stridulus, are not always 
identical. In some ca>es they appear to be dependent upon an e 
sive accumulation of mucus in the swollen air pass _ - in other eases 



DISEASES OF THE LARYNX. 427 

the symptoms are the result of an excessive irritability of the nervous 
system, by which are produced spasmodic movements of the larynx, 
which, in association with inflammatory swelling, render the act of res- 
piration difficult. 

Chronic catarrh of the larynx. Chronic catarrh of the larynx fre- 
quently results from repeated attacks of acute laryngitis ; or it may 
occur as a complication of other diseases ; or as a result of long-con- 
tinued misuse of the voice. The symptoms resemble those of acute 
laryngeal catarrh, only they are characterized by a minor degree of 
severity. The quality of the expectoration always resembles that which 
is yielded during the advanced stage of acute laryngitis. Laryngo- 
scopy examination discovers redness of the mucous membrane, though 
less vivid than that which is apparent during the acute form of the dis- 
ease ; the bloodvessels are more prominent and tortuous than in health ; 
there is considerable swelling of the tissues, so that the vocal cords 
appear thickened, and the epiglottis may be quite deformed ; sometimes 
the mucous membrane presents a roughened, or villous, or granular 
appearance. In severe or chronic cases, the mucous membrane may 
exhibit erosions and ulcerations, especially upon the free border of the 
true vocal cords which are subjected to friction against one another in 
the act of phonation. Ulcerative processes are most frequently observed 
in cases that are dependent upon tuberculosis or upon syphilis or other 
infective diseases. Sometimes tumors of a polypoid or papillomatous 
character occur as a result of the chronic inflammation. The mucous 
membrane upon the inferior surfaces of the vocal cords sometimes be- 
comes greatly tumefied, and encroaches upon the glottis and upon the 
cavity of the larynx, to a degree that is productive of great danger from 
suffocation. 

Pathological Anatomy. The changes that are produced by chronic 
laryngeal catarrh are best observed with a laryngoscope during the life 
of the patient. Their general character has been already indicated. 
Microscopical examination reveals nothing more than the ordinary 
multiplication of connective tissue and epithelial cells, with the products 
of the inflammatory process. 

Diagnosis. No difficulty attends the diagnosis when it is based upon 
laryngoscopic examination. Without such investigation it is impossible 
to infer the nature or extent of the morbid processes that are concealed 
from view. (Fig. 95.) 

Prognosis. The prognosis in catarrhal inflammation of the larynx 
depends upon the causes of the disease. In simple, acute cases, it is 
favorable. Chronic cases are liable to become very tedious, and relapses 
are frequent. Syphilitic and tubercular cases are sometimes attended 
with great danger. 

Treatment. The necessary constitutional treatment has been already 
indicated, in connection with coryza and chronic catarrh of the nasal 
passages. The treatment of acute laryngeal catarrh is identical with 
that already recommended in cases of coryza. Cough may be relieved 
by Dover's powder, in one-grain doses every two hours, or by the use 
of morphine — the thirtieth of a grain of morphine, with a drop of dilute 
hydrocyanic acid, may be given every two hours for the same purpose. 



428 






z :■ 7. ?t A >" 



r: : :• 



Various medicated troches containing 



>piates, and chloride 



of ammonium, are frequently employ ed with great benefit. Inhalations 
of the vapor of warm water, medicated with one to five per cent, addi- 
tions of common salt, or the bicarbonate of sodium, or chloride of 



"-•-.?: 




a. Laryngeal mirror, pushing back uvula, bat not touching vail of pharynx, c Left 
vocal cord, a. Mirror introduced through wound in trachea after tracheotomy — infra- 
glottic laryngoscopy. (Moekll Mackkszik. ) 



ammonium, are useful. U - disable to commence with weak solutions, 
and gradually to increase their strength. They may be repeated as often 
as may be found agreeable to the patient, but the remedy must be changed 
erery three or four days, on account of the tolerance that is establis 
by the constant use of the same substance. The most convenient form 
of apparatus for the administration of inhalations is the ordina: 5 



DISEASES OF THE LARYNX. 429 

spray-producer. In acute cases this may be kept in constant operation 
near the patient. In milder attacks it is sufficient to employ the inha- 
lation every two or three hours. 

When expectoration is copious and unattended by any difficulty, the 
inhalation of astringent sprays should be recommended, e. g., nitrate of 
silver (one-tenth of one per cent.), tannic acid or alum (one to three per 
cent.), sulphate of zinc (one-tenth to one-half of one per cent.), liquor 
ferri perchloridi (one-tenth of one per cent). 

Laryngismus stridulus can be promptly relieved by placing the 
patient's feet in a hot mustard bath, with a mustard poultice over the 
upper part of the thorax, and ipecacuanha in quantity sufficient to pro- 
duce vomiting. Cases in which spasm is the prominent feature fre- 
quently yield very quickly to the inhalation of ether ; but this must be 
employed with caution in the vicinity of lights or fire, on account of its 
inflammable character. Perspiration should be encouraged with copious 
draughts of hot herb tea. If death from asphyxia cannot be otherwise 
averted, intubation of the larynx, or tracheotomy, may become neces- 
sary. During the daytime, after a paroxysm of laryngismus, the patient 
should be thoroughly treated with expectorant doses of ipecacuanha, by 
which means a recurrence of the paroxysm may be averted. The treat- 
ment of chronic laryngeal catarrh consists largely in the local use of 
astringent powders, e. g., tannic acid, acetate of lead, or alum, which 
must be introduced into the larynx by insufflation with an appropriate 
instrument; a small quantity of powder, not more than a grain, or a 
grain and a half at a time, should be introduced into the tube, and 
while the tongue is drawn forward, it may be blown directly into the 
larynx. The operation is at first very disagreeable to the patient, but 
its daily repetition renders it more tolerable. 

The general medication of chronic laryngeal catarrh should be guided 
in great measure by the history of the patient. Syphilitic cases require 
specific treatment ; tubercular patients must be treated with reference 
to that special form of infection ; rheumatic or gouty subjects require 
the remedies that are appropriate to their predisposition ; for such cases 
the long-continued use of mineral waters that contain sulphur, or the 
daily administration of sulphur in small doses. 

& . — Lac. sulphur gr. v. 

Potass, bitart • . gr. j. 

Sacchar gr. x. — M. 

S. — Once or twice every day will be advantageous. 

For additional particulars the student is referred to the larger man- 
uals and special monographs. 

(Edema of the Glottis — (Edema Glottidis. 

(Edema of the glottis is the name that is applied to such constrictions 
of the glottis as are produced by liquid accumulations in the sub-mucous 
connective tissue, whether they be of a serous or of a purulent character. 
This process usually occurs in the loose tissues upon the posterior sur- 
face of the epiglottis and in the aryepiglottic folds. It may extend 



430 DISEASES :r the ORGANS of respiration - . 

downward into the larynx itself. The swelling is usually bilateral : 
but it may be sometimes limited to one side, when it is dependent upon 
unilateral compression of the veins. The mucous surface appears pale 
when the affection is caused by simple obstruction : preceding condil 
of inflammation occasion the display of a brighter color. On incision 
into the tissues a transparent serous fluid escapes : or they may present 
a gelatinous appearance with very little discharge : or they may be 
infiltrated with pus. 

Etiology. (Edema of the glottis usually follows as a complication 
of laryngeal cUseast : it may also result from wounds or i :f the 

larynx, or as a consequence of the passage :■: a: fstu. U 

within the glottis, or as the result of inJ ~ >f si Ming and irrita- 
ting vapors; it may occur as a consequence of the :: 

- :n from neighboring localities : and it is witnessed, sometimes, as a 
sequel of infective diseases , or of Bright?* Jista*^. and of 
dist a sag of the hea/i: and lungs. Comr yf the laryngeal 

•s in the vicinity of the larynx, or within the thorax, may produce 
a genuine, non-inflammatory «:edema of the glottis. In certain cases, 
however, it is impossible to assign any particular cause for the origin 
of the difficulty. The disease occurs more frequently among men than 
amon^ women, between the eighteenth and fiftieth years of life. 

Stmpioms. CEderna of the glottis sometimes arises suddenly, and 
terminates life with astonishing rapidity. In other cases, however, its 
origin is gradual, and the symptoms which precede its evolution suc- 
ceed one another with varying severity for a considerable time : : 
the final explosion. These cases are less dependent upon inflamm 
than the first class of cases. 

The prominent symptom of '.edema of the glottis consists in obstru t 

and difficulty in the act of inspiration. The voice becomes hoarse and 

disappears : there may be a barking cough : inspiration is stridulous 

and laborious : cyanosis appears, and the phenomena of asphyxia are 

red by death, unless assistance can be promptly affoi 

If the tongue be grasped with a napkin and drawn forward, it may 
be possible with the laryngoscopic mirror to look upon the picture of 
the cedematous glottis and its tumefied periphery. The epiglottis - 
often converted into a thickened tumor by which the orifice of the 
glottis is more or less completely concealed. In other eases the iema- 
tous tissues project over or between the vocal _' more or 

less complete obstruction of the passage. 

There may be considerable complaint of local pain in the thi 
which is increased by the act fswall wing, . by pressure upon the 
■ edematous parts. 

DIAGNOSIS. The use of the laryngoscope greatly facilitates diagr. - - 
though the introduction of the mirror may be attended with considerable 
difficulty if the symptom- of asphyxia are urgent. 

Prognosis. The prognosis is very grave, - I far from - 

five per cent, of report seal eached a fatal termina: 

Treatment. In ca-es that are dependent upon acute inflammation, 
the suction of - les gi - relief. External counter-irritation 

with lee/ s 3 with mustard, or with blisters, is useful when the 



DISEASES OF THE LARYNX. 431 

symptoms are not sufficiently urgent to require more radical inter- 
ference. 

Cases in which the symptoms are principally dependent upon cedema- 
tous and dropsical conditions, may be sometimes relieved by the opera- 
tion of hydragogue cathartics, e. (/., compound infusion of senna with 
sulphate of magnesia, compound cathartic pills, or croton oil. 

But if oedema be rapidly developed, with increasing symptoms of 
asphyxia, it becomes necessary to resort to surgical interference, which 
may be accomplished by scarification of the oedematous tissues with a 
properly guarded bistoury. A blunt-pointed bistoury, wrapped with 
sticking-plaster to within a quarter of an inch of its point, may be 
guided, by the aid of the laryngoscopic mirror, into the opening of the 
glottis, where active incisions will usually give prompt relief. Should 
this method fail, it will be necessary to attempt intubation or trache- 
otomy. Operative interference must not be delayed too long ; a fatal 
result has often occurred during the absence of the physician in search 
of his instruments. 

Perichondrial Inflammation of the Larynx — Perichondritis Laryngea. 

Etiology. Inflammation of the laryngeal perichondrium seldom 
occurs as a primary disease ; it usually follows inflammations and ulcera- 
tions of the larynx, notably after infective diseases. 

Pathological Anatomy. The disease is most commonly witnessed 
in connection with the arytenoid cartilages ; and, in successive order of 
frequency, it may affect the cricoid, the thyroid, and the epiglottic car- 
tilages. 

The inflammation usually extends from the surface to the perichon- 
drium, where it excites a suppurative process with consequent separation 
of the perichondrium from its cartilage. The formation of such 
abscesses is itself attended with danger from the constriction of the 
glottis that is thus produced, and from the liability to oedema that is 
thus induced. By reason of the arrest of nutrition that follows a 
solution of continuity between the perichondrium and the subjacent 
cartilage, the affected portion of the laryngeal cartilage falls into a con- 
dition of necrosis which may result in its absorption or in the discharge 
of detached portions of necrosed tissue. In this way, an additional 
source of deformity and constriction of the laryngeal cavity may be 
originated. 

Symptoms. When perichondritis occurs as a secondary consequence 
of other laryngeal diseases, its symptoms are liable to confusion with 
those of the primary disease ; only when it occurs as a primary inflam- 
mation is it easy to recognize its characteristic phenomena. 

When the disease is limited within a narrow space, there is com- 
plaint of a localized pain, which, when it principally involves the pos- 
terior portion of the larynx, is increased during the act of deglutition. 
When the external surfaces of the larynx are affected, there may be 
swelling and redness of the superficial tissues in the neck, with pain on 
pressure over the thyroid cartilage. The neighboring lymphatic glands 
may also participate in the swelling. The voice is generally affected by 



432 DISEASES OF THE ORGANS OF RESPIRATION. 

reason of the swelled and obstructed condition of the laryngeal orifice, 
or as a consequence of difficulties affecting the muscular apparatus of 
the organ. The act of respiration is also impeded by the production of 
inspiratory dyspnoea. 

The laryngoscopic mirror renders it easy to locate the site and the 
nature of the process by which the above-mentioned symptoms are 
produced, when the degree of swelling is sufficient to obstruct the 
glottis. 

The course of laryngeal perichondritis exposes the patient to great 
danger. The sudden evacuation of an abscess, or the occurrence of 
complicating oedema of the glottis, may occasion asphyxia and sudden 
death. Fistulous openings sometimes remain as an indication of previous 
necrosis involving the laryngeal cartilages. In some cases a communi- 
cation with the cavity of the larynx has thus been opened directly 
through the tissues and skin of the neck. Septicaemia and pulmonary 
abscess or gangrene, or chronic pulmonary diseases, may be excited as 
a consequence of purulent infection. Complete cessation of the inflam- 
matory process, with local cicatrization, sometimes only adds to the 
dangers of the patient by the deformity and constriction of the larynx 
that may be thus produced. The prognosis is therefore very unfavor- 
able. 

Treatment. Local inflammation without suppuration requires local 
antiphlogistic treatment, e.g., ice-bags over the larynx, small pieces of 
ice internally, and the application of three or four leeches over the 
thyroid cartilage, or lower down, if it be desirable to conceal the scars. 
Counter-irritation with tincture of iodine or with croton oil may be 
employed as the case progresses Syphilitic patients require active 
treatment with iodide of potassium, five to ten grains three times a day : 
or the inunction of mercurial ointment daily for a month. Pain may 
be relieved by pencilling the epiglottis and the cavity of the larynx 
with a ten per cent, solution of cocaine. The formation of abscesses 
require surgical interference with a properly guarded bistoury, guided 
by the aid of the laryngoscopic mirror. After the evacuation of the 
abscess, the patient should inhale disinfectant sprays, e.g., two or three 
per cent, solutions of carbolic acid, boric acid, benzoate of sodium, or 
the liquor aluminii acetici. The symptoms of asphyxia must be 
obviated by intubation or by tracheotomy. Severe laryngeal stenosis 
may render it necessary to wear the tracheal canula during the re- 
mainder of life. 



LARYNGEAL NEUROSES. 433 



CHAPTEE III. 

LARYNGEAL NEUROSES. 

Paralysis of the Laryngeal Muscles — Paralysis Musculorum Laryngis. 

Etiology. Laryngeal paralysis may be the consequence either of 
nervous disorder or of disease involving the muscular structures them- 
selves. The first class of affections is dependent upon diseases of the 
central nervous system or of the peripheral nerves, and may be associated 
with other evidences of paralytic disorder. The nature of the second 
class may remain obscure until death permits microscopical examination 
of the affected tissues. 

Laryngeal paralysis of nervous origin often occurs in consequence 
of cerebral hemorrhage, but more frequently in connection with chronic 
local degeneration affecting the pons Varolii or the medulla oblongata, 
e. g., multiple cerebro-spinal sclerosis, glosso-labio-laryngeal paralysis, 
tabes dorsalis, etc. It is frequently observed as a functional disorder in 
hysterical affections, or as a result of reflex inhibition. Rheumatic 
paralysis of the laryngeal muscles not uncommonly occurs among 
nervous persons who are predisposed to muscular rheumatism. 

Among peripheral causes of laryngeal paralysis may be mentioned 
the occurrence of tumors within the cavity of the cranium that press 
upon the roots of the pneumogastric nerve, or upon its trunk when 
situated within the neck or within the cavity of the thorax. In like 
manner the accumulation of liquids within the pericardium or the 
pleural cavity may compress the recurrent nerves and thus interfere 
with the movement of the laryngeal muscles. 

Local inflammation involving the laryngeal cavity, and previous 
infection with the contagion of infective diseases, notably diphtheria, 
and intoxication with lead, opium, and solanaceous preparations, are 
numbered among the exciting causes of laryngeal paralysis. 

Pathological Anatomy. In many cases no changes can be dis- 
covered either in the nerves or in the muscles of the larynx ; the patho- 
logical changes must be sought in the brain or elsewhere. In other 
cases the phenomena of chronic inflammation and degeneration may be 
discovered in the muscular tissues. 

Symptoms. It is impossible to recognize with certainty the exist- 
ence of laryngeal paralysis without the aid of the laryngoscope, since 
there are so many causes of a non- paralytic character which may inter- 
fere with the functions of the organ. (Fig. 96.) It must not be for- 
gotten that the muscles of the larynx are innervated by the pneumogas- 
tric and spinal accessory nerves whose united fibres supply, through 
the superior and inferior laryngeal nerves, the requisite innervation to 
the sensory and motor structures of the organ. The superior laryngeal 
nerve is the sensory nerve of the upper portion of the laryngeal cavity, 

28 



434 DISEASES OF THE ORGANS OF RESPIRATION. 

and of the vocal cords, and it also supplies motor twigs to the crico- 
thyroid muscle, and to the thyro-ary-epiglottic muscle by which the 
epiglottis is drawn backward over the glottis. The inferior laryngeal 
nerve is the motor nerve for all the other muscles of the larynx. 




The laryngeal image during quiet inspiration, ge. Glosso-epiglottic folds, u. Upper 
surface; I, lip, and c, cushion of epiglottis, v. Ventricle of larynx, ae. ary-epiglottic 
fold. cW. Cartilage of Wrisberg. cS. Capitulum Santorini. vc. Vocal cord. t. Tracheal 
rings. (Morell Mackenzie.) 

Paralysis of the laryngeal muscles may be either unilateral or 
bilateral ; it may involve a single muscle, or special groups of muscles, 
or all the muscles of the organ. 

(a) Paralysis of the posterior eric o- arytenoid. With the laryngo- 
scope it is easy to discover that paralysis of this muscle arrests the 
movements of the corresponding vocal cord. In cases of bilateral paral- 
ysis the vocal cords are not separated during the act of inspiration, but 
remain almost in contact with each other, thus producing noisy inspi- 
ration which may be succeeded by complete obstruction, if associated 
with slight swelling of the mucous membrane. 

(b) Paralysis of the arytenoid muscle prevents the contact of the 
posterior third of the vocal cords during the act of articulation, in con- 
sequence of the impossibility of approximating the arytenoid cartilages 
so as to close the posterior portion of the glottis. 

(c) Paralysis of the internal thyro- arytenoid muscle prevents the 
approximation of the anterior two-thirds of the vocal cords during the 
act of phonation. 

{d) Paralysis of the lateral thyro-arytenoid muscle, and 
(e) Paralysis of the external thyro-arytenoid muscle, do not permit 
of recognition by the aid of the laryngoscope. 

(/) Paralysis of the entire recurrent nerve produces complete immo- 
bility of the corresponding vocal cord, which remains motionless in a 
position half-way between the median line of the glottis and the position 
which it normally occupies during inspiration. (Figs. 97 and 98.) This 
position corresponds with that which is assumed by the margin of the 
glottis after death, hence the term cadaveric position applied to this 
paralytic state. Respiration obviously encounters no obstruction during 
the act of phonation. The opposite vocal cord, in cases of unilateral 
paralysis, extends itself be} 7 ond the median line so as to render utter- 
ance possible, though rough and difficult. The unparalyzed arytenoid 
cartilage also presses in front of and beyond its companion. 



LARYNGEAL NEUROSES. 



435 



(g) Paralysis of the crico-thyroid muscle. The crico-thyroid muscle 
assists in the extension of the vocal cords, by which the pitch of the 
voice is elevated. Paralysis, therefore, prevents such elevation of the 
pitch. Laryngoscopic examination discovers nothing of a characteristic 
nature. 

(K) Paralysis of the thyro-ary-epiglottic muscle. This muscle is 
innervated by the superior laryngeal nerve, and it acts as the depressor 
muscle of the epiglottis. Bilateral paralysis prevents the depression of 
the epiglottis during the act of swallowing, so that foreign substances 
are liable to intrude themselves within the larynx. In this way great 
irritation may arise, w T ith cough and subsequent inflammation, and the 
production of abscess or gangrene in the lungs, if foreign bodies find 
their way into the deeper respiratory passages. Such intrusion is more 
liable to follow complete paralysis of the superior laryngeal nerve, be- 
cause the consequent loss of sensibility in the upper part of the larynx 
hinders those reflex movements by which the glottis may be closed. 



Fro. 97. 



Fig. 98. 




Paralysis of the left recurrent nerve. 
Image during inspiration — the left cord 
in the cadaveric position. (Morell Mac- 
kenzie.) 




Paralysis of the left recurrent nerve. 
Image during phonation — left cord in ca- 
daveric position. (Morell Mackenzie.) 



Functional paralysis and intermittent paralysis of the laryngeal 
muscles have been observed as consequences of hysteria and of malarial 
infection. 

Prognosis. The probability of recovery depends upon the nature 
and cause of the disease. Paralysis of the posterior crico-arytenoid 
muscles is attended with the greatest amount of danger by reason of the 
consequent liability to asphyxia. 

Treatment. Treatment must be prophylactic, general, and local. 
Prophylactic and general measures should be addressed to the invigora- 
tion of the constitution and to the prevention of disorders that may 
become complicated with paralysis. Quinine, iron, strychnine, and 
arsenic, are the most efficient remedies in connection with general 
treatment. 

Local treatment consists chiefly in daily pencilling of the laryngeal 
surfaces with weak solutions of nitrate of silver, or in the daily insuffla- 
tion of astringents (p. 429), and the employment of electricity. The 
faradic current may be applied externally with just sufficient strength 
to effect contraction when applied to the facial muscles ; or it may be 
applied directly to the paralyzed muscles by means of a laryngeal elec- 
trode, guided by the aid of the laryngoscopic mirror. Hysterical paral- 
ysis may be sometimes very promptly and unexpectedly relieved by the 



436 DISEASES OF THE ORGANS OF RESPIRATION. 

use of powerful electrical currents, or by some strange and unexpected 
manoeuvre that arouses the attention of the patient. 

Impending asphyxia, dependent upon paralysis involving the posterior 
cricoarytenoid muscles, must be relieved by intubation or by trache- 
otomy. Paralysis of the depressor muscles of the epiglottis may render 
it necessary to resort to artificial feeding with the aid of an oesophageal 
sound. 

Spasm of the Glottis — Spasmus Glottidis. 

Etiology. Spasm of the glottis is a functional disease that is char- 
acterized by the occurrence of brief paroxysms during which the open- 
ing of the glottis is spasmodically closed, and respiratory movements 
are arrested. It is most frequently encountered during the first two 
years of life, among male children who are the victims of rickets or of 
tuberculosis of the lymph glands. It occurs, therefore, among bottle- 
fed babies who manifest the restless irritability and unhealthy nutrition 
which characterize the rickety constitution. 

Symptoms. Paroxysmal arrest of respiration constitutes the pro- 
minent symptom of spasm of the glottis. Kespiration suddenly becomes 
irregular and shallow ; then, after a few deep inspirations, the breath 
ceases : the child becomes pale or cyanotic, with feeble and irregular 
movements of the heart, and swelling of the veins in the neck ; some- 
times there is involuntary evacuation of urine and feces ; the diaphragm 
is depressed and motionless, and the patient appears as if at the point 
of death, when, suddenly, with a long. deep, and stridulous inspiration, 
breathing is renewed ; the child opens his eyes, and soon appears as 
well as ever. The whole paroxysm occupies but a few seconds, or half 
a minute, at the longest. The paroxysms may be of rare occurrence, or 
they may be repeated many times a day. 

The occurrence of spasm is not always limited to the respiratory 
muscles, but it sometimes extends to the extremities of the body, with 
the production of convulsive movements that mark a relationship be- 
twen this disorder and general convulsions. Death sometimes occurs 
as a result of asphyxia. 

Pathological Anatomy. Post-mortem examination indicates a 
great variety of pathological disorders, involving the lymphatic system 
and the circulation of blood; but nothing that is uniformly character- 
istic or explanatory of the spasmodic phenomena. The disorder appears 
to be a neurosis that depends upon reflex excitement associated with 
central or peripheral errors of nutrition. 

Prognosis. The prognosis in cases of spasm of the glottis must be 
very guarded. Danger arises not so much from the occurrence of spasm 
as from the cachectic condition of the patient. 

Treatment. Prophylactic treatment requires the adoption of such 
measures as will improve the nutrition of the patient. Nurslings who 
are deprived of mother's milk should be provided with a wet-nurse, and 
unwholesome hygienic conditions must be rectified as for as possible. 

On the occurrence of a paroxysm the child must be placed in the erect 
position, because pressure upon the back of the head frequently pro- 
vokes or prolongs the spasm. A warm bath, and sprinkling of the lace 



LARYNGEAL NEUROSES. 437 

with cold water, are useful. If the paroxysm be unusually prolonged, 
the mouth should be opened, and the attendant should endeavor with 
the forefinger to draw the tongue forward, and thus to arrest the spasm. 
A repetition of the attack may call for the administration of ether, or 
of chloral. Intubation may become necessary, and will, probably, if 
employed, obviate the necessity for tracheotomy. The use of faradic 
electricity about the neck and diaphragm has been recommended. 
Bromide of potassium may also be employed with advantage, especially 
if associated with attention to the diet and digestive organs. 

A somewhat similar spasmodic affection of the laryngeal muscles is 

sometimes observed among hysterical adults, or as a consequence of 
hydrophobia, or lead poisoning, or the pressure of tumors upon the 
branches of the pneumogastric nerve, or after the inspiration of irrita- 
ting gases, or the introduction of foreign bodies within the cavity of the 
larynx. Nervous persons, under the influence of fatigue and excite- 
ment, sometimes manifest, during paroxysms of cough, a tendency to 
laryngeal spasm that may be distressing or even dangerous. Under 
such circumstances accurate coordination of the laryngeal muscles may 
become temporarily attended with difficulty, so that articulation is per- 
formed in an imperfect manner, or fails entirely, for the time being. 
Such conditions are obviously aggravated by the intercurrence of slight 
catarrhal inflammation of the laryngeal mucous membrane. 

Anaesthetic conditions of those portions of the mucous membrane 
that lie under the control of the superior laryngeal nerve are sometimes 
observed after diphtheria, or during the course of glosso-labio-laryngeal 
paralysis. The affection sometimes occurs in connection with hysteria. 
As a consequence of such anaesthesia, particles of food are very liable 
to find their way into the respiratory passages, where they may excite 
severe inflammation. 

Hyperesthesia of the laryngeal mucous membrane is sometimes ob- 
served among nervous patients who have over-exerted their vocal organs. 
In such cases a sensation of burning pain, or of tickling, in the region 
of the larynx may rise to the level of severe neuralgia. It must be 
relieved by the use of narcotics, and by restoration of the general 
health of the patient. 

Laryngeal cough is most frequently observed among young women 
of an hysterical predisposition. The cough is paroxysmal, and some- 
times assumes a peculiar hoarse and muffled sound, that is frequently 
compared to the barking of a dog. 



438 DISEASES OF THE ORGANS OF RESPIRATION. 



CHAPTEE IV. 

DISEASES OF THE TRACHEA AXD BEONCHI. 

Catarrhal Inflammation of the Bronchi — Bronchitis Catarrhalis. 

Etiology. Catarrhal inflammation of the trachea is so intimately 
associated with inflammation of the bronchi, and its symptoms are so 
nearly overshadowed by the symptoms and causes of bronchitis, that it is 
unnecessary to consider them apart from those of bronchial inflamma- 
tion. Bronchitis may involve the air passages upon one or upon both 
sides of the thorax ; it may be limited to a single bronchus, or it may 
involve every branch of the bronchial tree ; it may occur as a primary 
disease, or it may arise as a complication of many other diseases. 

The most common cause of primary bronchitis is exposure to damp- 
ness and cold. It often occurs in the spring and fall of the year, when 
the weather is exceedingly variable and damp. It occurs most fre- 
quently at the extremities of life. Many persons exhibit a predispo- 
sition to inflammation of the respiratory mucous membrane, and are 
liable to attacks of bronchitis under circumstances which would excite 
some other form of inflammation, or would produce no result whatever, 
in the case of other individuals who were subjected to the same kind of 
exposure. The existence of anaemia, or tuberculosis, or the rickety 
diathesis, is a powerful predisposing cause of the disease. Patients who 
have been debilitated by malaria, syphilis. Bright' s disease, diabetes, 
gout, scurvy, or alcoholism, present very little resistance to the exciting 
causes of bronchial inflammation. 

Prominent among exciting causes of bronchitis is the respiration of 
air that is charged with irritating gases, or loaded with particulate 
dust. For this reason many occupations are especially dangerous to 
artisans or laborers. 

Without mentioning the deleterious effects that result from inhala- 
tion of certain chemical gases and vapors, it is worthy of note tlmt par- 
ticular drugs sometimes excite severe bronchial inflammation when 
they are administered for medicinal purposes. Thus it is frequently 
impossible to make use of ipecacuanha, or iodide of potassium, or of 
bromide of potassium. Mercurial preparations sometimes appear to 
excite a similar tendency. 

It is doubtful whether vocal exercises can produce bronchial inflam- 
mation by any direct effect upon the mucous membranes : it is more 
likely that the frequent occurrence of bronchitis among such subjects 
is the result of incautious exposure after becoming very much heated 
by vocal effort. 

Secondary bronchitis usually occurs as the result of pulmonary 
diseases, or in consequence of obstruction to the circulation which has 



DISEASES OF THE TRACHEA AND BRONCHI 439 

its origin in heart disease or in such disorder of the abdominal organs 
as hinders the efficient circulation of the blood. 

The occurrence of bronchitis as a complication of laryngeal inflam- 
mation, or as a sequel of the infective diseases, has already been men- 
tioned. 

Pathological Anatomy. In acute bronchitis the mucous mem- 
brane that lines the bronchi exhibits unusual redness and swelling ; 
sometimes the larger bloodvessels become visible to the naked eye ; 
and, occasionally, minute extravasations of blood are visible under the 
epithelial surfaces. At first the mucous membrane appears velvety 
and unusually dry ; but, presently, the secretion of the mucous glands 
becomes copious, and their ducts are distended with minute, pearly 
drops, which exude into the bronchial passage, and cover its surface 
with a thick, transparent, and slimy liquid. If the inflammation 
involves the smaller bronchioles, they may become completely obstructed 
by this secretion so that air can with difficulty enter the alveolar pas- 
sages, and cannot escape from them during expiration. The lungs, in 
consequence, become expanded and emphysematous ; this change is 
most commonly observed along the anterior border and inferior surface 
of the pulmonary lobes. Sometimes a considerable bronchus becomes 
obstructed, with subsequent collapse of the dependent portion of the 
lung tissue, constituting what is called atelectasis. This differs from 
other diseases that are characterized by the absence of air in the pul- 
monary alveoli through the fact that the collapsed portion of the lung 
may be easily filled with air by insufflation through the obstructed 
bronchus. But, sometimes, it happens that the alveoli are themselves 
occupied by inflammatory exudations as a consequence of an extension 
of the inflammatory process from the adjacent bronchioles, constituting 
catarrhal pneumonia or broncho -pneumonia. 

An incision through the lungs, after death from catarrhal bronchitis, 
causes a discharge of frothy, or more or less sero-purulent, liquid from 
the smaller bronchial passages. 

Chronic catarrhal bronchitis is limited to the larger bronchi ; their 
mucous lining is considerably thickened, and exhibits a darker color 
than that which characterizes acute bronchitis. The mucous membrane 
presents extensive proliferation of tissue, especially involving the elastic 
layers, while the muscular fibres are considerably atrophied. Some- 
times, in chronic cases, the mucous membrane becomes very thin and 
pale, so that it resembles a serous membrane in its general appearance. 

The bronchial secretions present variable characteristics, being some- 
times thick and tenacious and richly endowed with pus corpuscles, or 
they may be of a thin and watery quality ; sometimes decomposition 
takes place within the bronchi, and the sputa become putrid and 
horribly offensive. 

Sometimes the inflammatory process extends beyond the mucous 
membrane, and invades the peribronchial connective tissue, exciting 
interstitial inflammation of the lungs. Sometimes the lymphatic vessels 
and bronchial lymph glands are thus invaded. Pulmonary emphysema 
may also develop as a consequence of chronic bronchial catarrh. 



440 DISEASES OF THE ORGANS OF RESPIRATION. 

Symptoms. Acute inflammation of the larger bronchi commences 
with a sensation of soreness under the sternum, accompanied by an 
inclination to cough, but without any considerable amount of expectora- 
tion. A febrile movement is not uncommon, and among children it 
may be attended by severe symptoms of cerebral disturbance, or by 
convulsions. 

Auscultation reveals the existence of coarse rales which are audible 
between the shoulder-blades and in the lateral portions of the thorax. 
These sounds are produced by the occurrence of local accumulations of 
mucus upon the inner surface of the bronchi, by which the movement 
of the air, during respiration, is somewhat obstructed, and audible 
sounds are originated. When the secretion is scanty and tough, the 
rales are of a sonorous and simple character, which is indicated by the 
term dry rede or rhonchus. A moist rode indicates the presence of a 
less tenacious and more fluid secretion. "When inflammation invades the 
smaller bronchi, the rales become finer, and assume a whistling or 
hissing character, hence the term sibilant rdle that is applied to such 
sounds. When these sounds originate near the surface of the lung, 
they are clear and audible, but when originating in the deeper portions 
of the organ, they assume a somewhat muffled character : they never 
manifest a resonant quality. 

As the disease progresses, the bronchial secretions become more 
copious and exhibit an increasing quantity of pus cells in the semi-fluid 
mass. The originally mucous sputa thus become transformed into 
muco-purulent or sero-purulent accumulations. The character of the 
respiratory sounds indicates a similar transformation. Dry and 
sonorous at first, the rales become moist and sibilant as the process of 
liquefaction goes on. The respiratory sound frequently becomes pro- 
longed in consequence of obstruction to the outflow of air through the 
constricted bronchi. Inspiratory sounds lose their delicate vesicular 
quality and become coarse and shrill, with staccato-like intermissions, in 
consequence of interference with the normal vibration of the bronchial 
membranes. 

The cough by which the patient is annoyed is severe in proportion to 
the amount of inflammation at the bifurcation of the trachea, which has 
been experimentally shown to be the most irritable portion of the 
bronchial tree. At first, expectoration is very scanty, but with the 
progress of the disease it becomes copious, and the sputa exchange their 
tenacious, frothy, and glairy transparency for a more fluid and purulent 
quality. As the disease subsides, cough and expectoration diminish, 
and finally cease altogether. During the height of the cough a certain 
degree of hoarseness is sometimes observed. The intercostal and 
abdominal muscles sometimes become tender and painful, in consequence 
of the excessive efforts that are required of the respiratory muscles. In 
severe cases, vomiting, or the involuntary evacuation of urine and feces, 
may occur during paroxysms of cough ; hernia, prolapse of the anus, 
and premature delivery, have also been thus occasioned ; not unfre- 
quently the return of blood through the jugular veins is hindered 
during the paroxysms of cough to a degree that produces headache, 
dizziness, noises in the ears, and other evidences of venous hyperemia 



DISEASES OF THE TRACHEA AND BRONCHI. 441 

within the cranium. The duration of the disease is seldom more than 
one or two weeks. 

Acute catarrhal inflammation of the bronchioles, sometimes called 
capillary bronchitis, is produced by the extension of the inflammatory 
process to the ultimate branches of the bronchial tree. It is attended 
with great danger, especially when it attacks old people or young chil- 
dren. During the infantile period of life, the bronchiole is relatively 
smaller than it is at a later period, consequently there is greater risk of 
its obstruction through inflammatory swelling of its mucous lining. The 
disease is also, among children, more liable to degenerate into a condition 
of catarrhal pneumonia ; among old people the danger generally arises 
from the tendency to exhaustion and asphyxia. 

The commencement of the disease is frequently associated with the 
ordinary symptoms of acute bronchitis ; in other cases it develops 
insidiously. The accompanying fever presents no characteristic features, 
though there is usually a morning remission, or a brief intermission. 
Respiration is hurried in proportion to the extent and severity of the 
inflammation. Expiration is prolonged, and, with children, is fre- 
quently terminated by a slight groaning sound. Auscultation discovers 
over the greater portion of the thorax, fine subcrepitant rales, some- 
times associated with the coarser sounds that originate in the larger 
bronchi. When the bronchioles are considerably obstructed, the thoracic 
walls exhibit considerable retraction during inspiration. This is 
especially conspicuous among children, because of the yielding character 
of their tissues. The occurrence of this symptom indicates that very 
little air finds its way into the pulmonary alveoli, and that the lung is 
very imperfectly expanded during inspiration, so that the superincumbent 
pressure of the atmosphere causes a compensatory depression of the 
thoracic walls; sometimes this affection of the lower portion of the 
thorax is associated with alveolar distention of the upper part of the 
lungs, caused by the imprisonment of inspired air which cannot escape 
during expiration. These respiratory difficulties serve to arouse the 
activity of the auxiliary muscles of respiration. The nostrils are ex- 
panded at the commencement of each inspiration, the head is drawn 
backward, the mouth is opened, the shoulders are elevated, and the 
pectoral and cervical muscles become tense. During expiration the 
abdominal muscles are also called into excessive action ; it becomes im- 
possible to lie down ; grown persons must sit up in bed, and infants 
insist upon being carried erect in their mother's arms. As the proper 
oxygenation of the blood diminishes, the patient becomes cyanotic, con- 
sciousness is clouded, and the phenomena of asphyxia terminate the 
course of the disease. 

Palpation and percussion of the thorax afford comparatively little 
information regarding the nature of the disease ; sometimes the vocal 
fremitus manifests trifling changes, and the occurrence of acute emphy- 
sema, along the anterior and lower borders of the lungs, may occasion 
an increased resonance on percussion. Circumscribed dulness that does 
not disappear after deep inspiration indicates the existence of broncho- 
pneumonia. Auscultation discovers a fine, inspiratory, sibilant rale. 



442 DISEASES OF THE ORGANS OF RESPIRATION. 

Vocal sounds remain unchanged, unless the large bronchi have become 
completely obstructed. 

The cough that accompanies capillary bronchitis is less severe than 
when the larger bronchi are inflamed. The sputa are, at first, similar 
to those which are expectorated during the early stage of acute bron- 
chitis ; with the progress of the disease they assume a muco-purulent 
character ; floating in water, they exhibit stringy processes which corre- 
spond with the finer ramifications of the bronchial tree. 

The heart sometimes exhibits dilatation and increased dulness on 
percussion affecting the right ventricle, in consequence of impediment 
to the passage of blood through the branches of the pulmonary artery. 
If the anterior portion of the lung become over-distended with air, the 
area of cardiac dulness will be somewhat diminished. If the obstruction 
of the pulmonary circulation reach a high degree, the liver and other 
organs may become enlarged through retrograde blood pressure. 

The duration of the disease varies from a few days to a number of 
weeks. 

Chronic catarrhal bronchitis can originate spontaneously or it may 
be the result of an acute attack. It chiefly occurs among elderly people 
who suffer with obstruction of the circulation, or whose occupation ex- 
poses them to the inhalation of dusty particles. Its course is most 
frequent during the cold, damp months of the year. The disease sel- 
dom exhibits any symptoms of fever, unless as a transitory sequence of 
acute exacerbations. 

Chronic bronchitis usually affects the larger bronchi, consequently 
the r&les that indicate its existence are coarse and sonorous, dry or 
moist. If the disease is associated with difficulty of respiration, the 
sterno-cleido-mastoid muscles sometimes exhibit considerable hyper- 
trophy ; the veins in the neck also become dilated, and, sometimes, ex- 
hibit visible pulsations. Under such circumstances the right side of the 
heart becomes dilated and hypertrophied, and in the later stages of the 
disease the usual consequences of obstructed circulation become mani- 
fest, e. g., oedema, dropsy, albuminuria, etc. The cardiac muscles may 
undergo fatty degeneration as a consequence of the deficiency of oxygen 
in the blood in connection with the inordinate amount of work that is 
laid upon them. Inflammation of the lungs sometimes occurs, or the 
patient may simply fall into a hectic condition, and gradually waste 
away. Pulmonary consumption sometimes terminates life. 

As a consequence of chronic bronchitis it sometimes happens that 
the bronchi become dilated ; in other cases the air cells are distended, 
producing emphysema of the lungs. Occasionally the bronchial secre- 
tion undergoes putrefaction which may lead to gangrenous processes in 
the lungs. 

The disease tends to become more and more firmly established, and 
may continue for many years, or throughout the whole course of life. 

Certain varieties of bronchitis require special notice. 

(a) Dry bronchitis is a chronic form of bronchial catarrh, character- 
ized by scanty, tenacious and gray sputa ; it is usually observed in old 
people, and frequently results in the production of emphysema. 

(b) Simple bronchorrhoea is characterized by very copious sputa, 



DISEASES OF THE TRACHEA AND BRONCHI. 443 

of a mucopurulent character, of a greenish color, and somewhat frothy ; 
the amount of discharge affords no indication regarding the severity of 
the disease. 

(c) Serous bronchorrhoea is characterized by the expectoration of 
very thin, transparent, colorless, and frothy sputa ; it is often associated 
with a certain amount of dyspnoea of an asthmatic character, which is 
temporarily relieved by severe paroxysms of cough and copious expec- 
toration. 

(d) Broncho-blennorrhoea is characterized by the expectoration of 
purulent sputa, richly charged with pus corpuscles, fatty granules, and 
detritus ; the discharge differs from the contents of a. pulmonary abscess 
chiefly in the absence of elastic fibres and pulmonary tissues in the 
expectorated masses. 

(e) Putrid bronchitis is characterized by the expectoration of sputa 
in which the process of putrefaction has been set up by the action of 
putrefactive bacteria. The stench that is exhaled by the patient is 
frightful, and, sometimes, suffices to destroy the appetite on the part of 
the sufferer ; the odor differs from that of ordinary foul breath by its 
greater pungency and pervasiveness. The sputa are generally very 
abundant, fluid, gray or brown in color ; if allowed to stand for some 
time in a dish, the mass separates into four quite distinct layers, of 
which the superficial layer is frothy, the middle layers are serous, and 
the lowest resembles a sediment in which are found the characteristic 
particles which contain bacteria. Microscopical examination indicates, 
along with pus corpuscles, a fatty, pigmentary debris, various micro- 
organisms, and the presence of the parasite, Leptothrix pulmonalis. 
The absence of tissue cells derived from the parenchyma of the lungs 
affords a certain indication that the offensive odor is not due to gangrene. 
The general condition of the patient, also, is inconsistent with the pros- 
tration and rapid destruction that accompany gangrenous processes. 
It is not an uncommon thing, however, for putrid bronchitis to excite a 
suppurative fever, and to terminate life with the symptoms of uncon- 
trollable diarrhoea or hemorrhage. 

Diagnosis. The diagnosis of catarrhal bronchitis seldom presents 
any special difficulty. The characteristic symptoms are few in number ; 
the presence of rales, diminution of the respiratory sounds, high-pitched 
and intermitting vesicular inspiration, p>rolonged expiration, and ab- 
sence of dulness on percussion, are sufficient to decide the diagnosis. 
Coarse rales indicate the larger bronchi as the seat of the disease ; 
sibilant rales originate in the smaller bronchi, while still finer rales 
indicate the extension of disease into the capillary bronchi ; dry rales 
indicate the existence of tenacious secretions ; while moist rides indicate 
a more fluid character. Acute and chronic bronchitis may also be dif- 
ferentiated by their mode of commencement, and by their duration. 
The quality of the sputa is not without significance. 

Bronchitis may be differentiated from pneumonia by the absence both 
of dulness on percussion, bronchial breathing, crepitant rales, increased 
bronchophony, and vocal fremitus. 

Bronchitis may be differentiated from dry pleurisy by the disappear- 
ance of apparent friction sounds immediately after the paroxysms of 



444 ::5eases .7 :z: 7 - . . : - :■ ? .-.:>; :?.a::;: 

cough, which have no influence upon genuine friction ; Pi -sure 

with the stethoscope upon the thoracic wall, moreover, produces no 
change in the bronchial sounds, whilr ierably increases the inten- 

rity : pleuritic sounds. 

Pb ihosis. The results of bronchial catarrh are exceedingly vari- 
able. Among old people and children the acute diseac - attended 
with great danger. Capillary bronchitis, also, is a dangerou- 
The occurrence of complications renders the prognosis much more 
serious. Chronic forms of the disease are less likely to recover than 
the acute forms. 

Treatment. — Since bronchitis frequently implies a certain predis- 

m :::on on the part of the patient, it is desirable to employ measures 

that tend to increase his resistance. Daily sponging with 

cold water, the use of the flesh-brush, abundan: in the open 

air. with proper regulation of the diet, and avoidance of the exciting 

:: the disease, are the principal measures that require attention. 

The exister .- of rickets, chlorosis, anaemia, marasmus, or a piedis 

sition to tuberculosis, or arthri: liseases, most be corrected is far as 

ole. 

At the outset of an acute bronchitis the ordinary antifebrile treat- 
ment with antipyrine. acetanilide. or phenacetine may be undertaken 
in association with hot-foot baths, sinapisms, etc ^gh may be 

allayed by small doses of opiate remedies 

R . — Pniv. ipecac et opii gr. v. 

B — '-toe such powder three times a day. 

R — M ^Tilph. . . _ : 

Aei<L hydrocyan. dilut. .... ftyxxx. 

Byi simpL . . . . . . . jfae 

Aq. desulL ........ o— . :> -- — -I- 

B — A raspoonful every one or two hours. 

Narcotics must, however, be given with great cant children. 

and should never be administered if any cyan ippearaneee 

H abundant rales indicate copious secretion, it will be desirab. 
administer expectorant remedies : 

R. — Ammon chlorid- "5 - 

glyeyn liM. 5:-. — M. 

B — A e spoonful every two hours. 

R . — Apomorphin. st j. 

Aquae %xj. — M 

B — A teaspoonful every two hours. 

R. — P xass. iodid. ...... ~-- 

ipecac. z 

Aqu* .... ... jiij. — If. 

B — A teaspoonful every two hours. 

Ajh expectoration becomes more copious, especially if associated with 
a harassing cough, var tics and ectorants 

will be found useful. 



DISEASES OF THE TRACHEA AND BRONCHI. 445 

R. — Morph. sulph. ....... gr. iij. 

Spts. chloroform. ") 

Tr. cannab. ind. J ' a 3J- 

Tr. hyoscyam. \ 

Acid, phosphor, dilut. J aa 3 n J- 

Syr. ipecac. ) „ . 

Syr.scilhe } aa ^vj- 

Glycerin ^ijss. — M. 

S. — Half a teaspoonful every two hours. 

R . — Acid, benzoic. gr. jss. 

Ext. belladon gr. {-. 

Sacch. lact gr. viij. — M. 

S — One such powder every four hours. 

The room in which the patient lies should be kept at a temperature 
of 70° F., and the air should be moistened with the vapor of hot water. 
It is usual to recommend the addition of lime-water, or solutions of the 
alkaline salts, to the water that is diffused in the form of spray through- 
out the apartment. Oil of turpentine, carbolic acid, and tar-water may 
be thus employed. The direct inhalation of such medicated sprays, if 
practised frequently, is often serviceable ; the strength of the solution 
that is employed should not exceed one or two per cent. 

Great obstruction of the bronchial passages may sometimes call for 
relief through the aid of emetics (ipecacuanha, tartar emetic, sulphate of 
copper, apomorphine, etc.). Their use should not be deferred until 
asphyxia has deadened the reflex centres in the medulla oblongata, for 
then an emetic action often fails to occur. The administration of alco- 
holic stimulants a short time before the emetic dose often adds to its 
efficiency. Great prostration must be antagonized by the use of stimu- 
lants — e. g., wine, camphor, musk, aromatic spirits of ammonia, etc. 
Old people often require supporting treatment from the outset of the 
disease. 

A somewhat relaxed condition of the bowels often affords great relief, 
especially to young children ; for this purpose calomel in association 
with the sulphide of antimony may be given, either in the form of 
Plummer's pills, or in the form of a powder : 

R — Calomel. \ ... 

Stibii sulphid. J aa gr - J 

Sacch. lact. ........ gr viij. — M. 

S. — One such powder three times a day for an adult 

For instruction regarding the employment of pneumo-therapeutic 
measures in the treatment of bronchitis, the student is referred to 
special monographs on the subject. 

The treatment of chronic bronchitis often requires change of climate 
and occupation on the part of those who are able to secure such advan- 
tages. Long sea voyages, residence upon the sea-shore, and salt-water 
baths, are often found efficacious. Alkaline sulphur waters, and the 
long-continued use of small doses of sulphur, exert a favorable influ- 
ence in rheumatic cases. During the summer season patients may be 
sent with advantage to the mountainous regions in New England, in the 
Adirondacks, and along the line of the Alleghany Mountains, or to the 
elevated regions of Colorado, New Mexico, and Arizona. During the 



DISEASES 7 FHE SAKS 7 RESPIRATION. 

winterthe - f the Gulf of Mexic ndtheinlai Ires ts in Georgia 

and the Carolinas. afford a desirable 

The occurrence of pain in the chest may be relieved by warm appli- 
cations and stimulating liniments, or dry cups : in severe cases the 
hypodermic injection of morphine and atropine may be required. The 
:ence of luei- be necked by hypodermic injection 

_ y the administration of lead and opium pills Asthmatic 

paroxysms are favorably influenced by the use of iodide of potassium. 

R. — Potass iodid. ~ 

" - 
- t:::: fi.fi 51J- — M. 

Aquae J 

5 — A :faspoonful every three ho:: - 

Excessive -eeretion and expectoration may be relieved by the inha- 
lation of balsamic remedies, and by their internal use 

R . — Ol. terebinth 5 

S, — Ten or fifteen drops, in milk, three times a day. 

R. — Terpin. hydrat 5j. 

TabelL no. rn. 

6 — *>ne tablet every three hours. 

Putrid bronchitis requires the treatment that will be recommended 
in cases of pulmonary gangrene. 

Fibrinous Bronchitis — fl roni hiti 5 Fibrinc 1 

: 3LOGY. Fibrinous bronchitis consists in the formation of fibrin- 

sts within the small bronchi. Such exudation sometimes occurs 

primary disease, but in other cases his sequence 

of previous inflammation either in the larynx or in the air cells of the 

The primary disease originates in the bronchi, and may e 
thence either into the larynx or into the air cells. It is a very rare 
disease. It commonly results from : but it has been 

observed in connection with mj - x>nse juence of 

y, or of menstruation. It has also been observed in alterna- 
tion with eruptions of impetigo, herpes, or pemf ■:. gos -:rnal 

MS . 1. tl smayej si 11 acute or as a chronic 

disease. The - form seldom lasts longer than a fortnight, but the 

ty may continue for many years, with a more 
mittent course. The acute disease is much more da _ - than the 
chronic, on account of the danger of extensive obstruction of the air 

ssagee —quent asphyxia. It is prone to attack the U _ 

bronchi, and to extend into the larynx, while the chronic Liseas 
chiefly manifested in the smaller air pass _ 

The characteristic symptom in both forms of ti. Ik - is tl 

tU which are formed by fibrinous exu-i 
from the bronchial mucous membrane. Previous to such expectoration 
the symptoms of bronchial obstruction and of asphyxia are mani: — 



DISEASES OF THE TRACHEA AXD BRONCHI. 



447 



in correspondence with the extent of the exudation. Death sometimes 
occurs in severe cases, before the discharge of any of the membranes. 
The occurrence of serious symptoms is generally preceded by the ordi- 
nary evidences of bronchial catarrh ; these may increase until haemoptysis 
occurs, before the discharge of the cast ; its evacuation is followed by 
the subsidence of these symptoms, which, however, may be renewed in 
cases of fresh exudation. 

Extensive obstruction of the larger bronchi may occasion inspiratory 
retraction of the thoracic wall', it will also be indicated by loss of 
motion in the affected part, diminished vocal fremitus, and the disap- 
pearance of respiratory sounds, with persistence of resonance on per- 
cussion. Dulness on percussion does not exist unless the air cells of 
the lungs are invaded by the inflammatory process, or when some por- 
tion of the lung becomes collapsed. 

The dimensions of the casts are subject to great variations ; sometimes 
they are small, and almost lost in the sputa; in other cases they may 
be equal to the length of the bronchial tree. (Fig. 99.). The larger 

Fig. 99. 




Fibrinous cast of bronchi; drawn full size, but the cast was slightly shrunken by 
keeping. (Dr. John Wilson.) 

portions are usually hollow, and contain muco-purulent matter, but the 
smaller branches are solid, and have, occasionally, undergone calcifica- 
tion. The color is white, gray, or brownish, according to the amount of 
pigment that enters into their composition. The tubes are formed of 
concentric lamelhe which consist of hyaline, fibrinous exudation, among 
the fibrils of which are entangled a few round cells, fatty granules, and 



44^ DISEASES OF THE ORGANS OF RESPIRATION. 

the debris of blood corpuscles. Various forms of epithelium are some- 
times adherent to the mass. 

Expectoration of the casts is followed by considerable relief from the 
preceding symptoms. Sometimes a single attack ends the disease, but 
generally the process of exudation is continued with repeated formation 
and evacuation of the resulting casts. If death occur, the bronchial 
mucous membrane appears red and swollen : very rarely is the opposite 
condition discovered. The epithelium beneath the casts sometimes 
remains uninjured, but it is often completely removed. 

PROGNOSIS. The prognosis in such cases is very doubtful, and must 
be given with great caution. 

Treatment. The removal and expectoration of the casts is facili- 
tated by constant inhalation of warm vapor, to which may be added 
one per cent, of any one of the alkaline salts, or two per cent, of lactic 
acid, or five per cent, of papayotine or of neurine. Expectorants, or 
emetics, may be used to assist in the discharge of the loosened casts 
(p. 444). Mercurial preparations and iodide of potassium are recom- 
mended as remedies for the arrest of exudation. 

Bronchial Dilatation — Bronchiectasis. 

Pathological Anatomy. Bronchial dilatation is usually observed 
in the medium-sized bronchi of the lower and middle lobes of the lungs. 
It sometimes affects a single bronchus, but generally a considerable 
number of branches are affected. It may result, as in the analogous 
case of arterial dilatation, in the formation of sacculated, cylindrical, or 
spindle-shaped dilatations. 

Cylindrical dilatation is characterized by a uniform swelling of the 
bronchus. Spindle-shaped dilatation may be associated with the pre- 
vious form : it is characterized by a tapering course of the expanded 
portion of the bronchus : sometimes a tube may be in different portions 
alternately dilated and contracted, in such a way as to produce the ap- 
pearance of a number of hollow beads connected by a tube. Saeeul t 
dilatation consists in the development of patches which may be formed 
by a lateral protrusion of the bronchial wall, or may involve the whole 
circumference of the tube. A bronchus may exhibit one or more such 
dilatations. The neighboring pulmonary tissue is generally affected 
by chronic interstitial inflammation, causing induration and dark dis- 
coloration of the pulmonary connective tissue. The dimensions of the 
dilated spaces vary greatly from almost imperceptible enlargement oi 
the bronchus up to a cavity equalling the size of a hen's egg, or even 

_ v. The bronchi that communicate with such dilated spaces some- 
times become occluded, giving origin to an isolated cavity filled with a 
fluid, which may become desiccated, or calcified. 

The mucous membrane within the dilated portion of the bronchus 
generally indicates some degree of chronic inflammation. It may be 
somewhat thickened, or, especially in sacculated bronchiectasis, un- 
usually thin and pale, resembling the appearance of a serous membrane. 
In some cases the membrane exhibits a transversly wrinkled appearance 
that is caused by local atrophy of the connective tissue and muscular 



DISEASES OF THE TRACHEA AND BRONCHI. 449 

cells of the mucous membrane, leaving the elastic tissues in the form of 
a prominent network. Occasionally the mucous membrane becomes 
ulcerated, especially when the secretions have undergone putrefaction. 
This condition is liable to be followed by hemorrhage or by gangrene of 
the adjacent lung tissue. Miliary tuberculosis, also, sometimes invades 
the unhealthy mucous membrane that has undergone dilatation. The 
lungs themselves are liable to chronic interstitial inflammation, or to 
pneumonic processes. Emphysema sometimes occurs, and catarrhal 
inflammation may involve the bronchi and the alveolar passages. The 
pleural surfaces frequently become adherent through the occurrence of 
adhesive inflammation. The right side of the heart may become 
dilated, with the development of consequent obstruction of the circula- 
tion. 

Etiology. Bronchiectasis is always connected with previous chronic 
diseases of the bronchi, lungs, or pleura. Capillary bronchitis, chronic 
bronchitis, and bronchial constriction, frequently lead to this condition. 
It is a disease that occurs more commonly at an advanced age of life, 
in men rather than women. The principal factor in the production of 
bronchial dilatation is found in the increased pressure of the air into 
circumscribed portions of the bronchial tree when, through the occur- 
rence of inflammation, or otherwise, considerable portions of the bronchi 
and of the pulmonary tissue have become impermeable. A yielding 
condition of the bronchial wall may be also produced by similar causes 
that have prevented the entrance of air into the obstructed portions of 
the lungs. Dilatation, therefore, follows in the same way and under 
similar conditions as in the analogous case of aneurismal formation 
affecting the arterial structures. 

Symptoms. In many cases the symptoms of bronchial dilatation 
differ in no way from the symptoms of chronic catarrhal bronchitis. 
Bronchiectasis may be suspected when occasional paroxysms of cough 
yield an excessive amount of expectoration. The patient may be able 
to sleep all night without disturbance, but, on rising in the morning, is 
seized with a violent attack of coughing and, sometimes, of vomiting, 
accompanied by an immense discharge of sputa which have accumulated 
during the night. So long as the contents of a dilated bronchus do not 
overflow into the bifurcation of the trachea, the reflex irritation by 
which the cough is excited does not occur. The amount of the dis- 
charge sometimes reaches a full quart in the course of a day, even 
though the general appearance of the patient does not seem to indicate 
any very urgent disease. The sputa contain round cells in all stages 
of degeneration, associated, sometimes, with more or less degenerated 
red blood-corpulscles and haematoidin crystals. Sometimes the sputa 
present a nummular form like that of the masses which are ejected from 
tubercular cavities, but they generally present a more irregular surface, 
and sink in water. 

On inspection, the lateral and posterior portions of the thorax some- 
times appear to be retracted. This is especially true of chronic cases 
associated with pleuritic adhesions or with interstitial inflammation of 
the pulmonary connective tissue. Inspiratory retraction is not unfre- 
quently associated with this condition, in consequence of the inability 

29 



450 DISEASES OF THE ORGANS OF RESPIRATION. 

of the lung to follow the outward movement of the thoracic wall. The 
attitude of the patient may suggest the locality of the bronchial dilata- 
tion, since he endeavors as far as possible by his position to avoid irrita- 
tion of the bronchial bifurcation with the contents of the enlarged 
bronchus. For this reason he generally seeks a recumbent position 
upon the diseased side. If dilatation have occurred in the upper portion 
of the lung, the constant outflow of the secretions keeps up a continual 
cough. 

Palpation gives different results in accordance with the amount of 
liquid that is contained in a bronchial cavity. After its evacuation 
fremitus is increased, but it again disappears when the cavity is once 
more filled with mucus. 

On percussion, the sounds that indicate the existence of the cavity are 
only clearly perceptible when the cavity is empty and is located near the 
thoracic wall. The characteristic tympanitic and metallic resonance is 
rarely obtained unless the dilated portion of the bronchus be at least 
three inches in diameter. The tympanitic sound is correspondingly 
muffled when the cavity is surrounded by lung tissue that is deprived 
of air. 

If the dilated bronchial cavity communicates freely with the trachea, 
percussion will yield a higher -pitched sound when the mouth is open 
than when it is closed ; and, as may be observed under similar con- 
ditions in connection with tubercular cavities in the lungs, percussion 
when the mouth is open occasions a peculiar modification of tympanitic 
resonance called the cracked-pot sound, from its resemblance to the 
characteristic note that is evoked by tapping upon the surface of a 
cracked pitcher or jar. 

In this connection it must be remembered that the tympanitic sound 
on percussion over the cavity, is produced by the vibrations of its walls 
which are excited by the blow. A sharp and metallic quality indicates a 
high degree of tension in the vibrating membrane ; hence the metallic 
resonance of smooth-walled, inflated cavities, in contrast with the duller 
note that is yielded by thick and flabby membranes. The higher pitch 
that is remarked when percussion is performed with the mouth open, 
and its reduction when the mouth is closed, are the results of changes 
which are thus effected in the length of the vibrating column of air. 
This is obviously longer when the mouth is closed than when it is open, 
for, in the first place, it extends from the cavity, through the communi- 
cating bronchus, trachea, larynx, pharynx, and nasal passages as fin* as 
the nostrils, while, in the second place, it is terminated, practically, at 
the entrance of the glottis. These changes of pitch and of quality 
depend upon the same changes of condition by which corresponding dif- 
ferences are effected in the case of musical instruments, e, g„ the flute, 
whose varying notes are produced by changes in the length of the vibra- 
ting column of air as the finger-stops are opened or closed. In like 
manner the different pitch and quality of sounds that, on percussion, 
are respectively yielded by large and by small cavities, are dependent 
upon conditions quite comparable to those which constitute the differ- 
ences between the sound of a bass drum and that of a snare drum. 

Ausculation indicates similar variations in the quality of the respira- 



DISEASES OF THE TKACHEA AND BRONCHI. 451 

tory sounds that accompany a bronchial dilatation. They are present 
when the cavity is empty, and disappear when it becomes filled with 
fluid. The rales which accompany accumulation of fluid in the bronchi 
vary in quality and in quantity according to the amount of exudation. 
They are associated with vesicular sounds when air finds access into the 
adjacent pulmonary cells. The sound of the voice becomes more audi- 
ble, and acquires a metallic resonance, when heard over a large and 
superficial cavity that is distended with air ; as it becomes filled with 
fluid secretion, bronchial sounds disappear. 

So long as the consequences of bronchial dilatation are restricted to 
the affected locality, the general health may be not seriously disturbed, 
but, if purulent absorption take place, a febrile movement occurs, and 
may assume a hectic character, and life may be terminated by exhaus- 
tion and diarrhoea. The limbs often become oedematous before death, 
as a result either of general innutrition, or of dilatation and failure of 
the right side of the heart, producing consequent obstruction of the cir- 
culation. Sometimes death occurs as a consequence of putrid bronchitis 
and subsequent gangrene of the lungs. It must be remembered, how- 
ever, that the existence of putrid sputa does not necessarily indicate 
the presence of bronchiectasis, for it may be the result of chronic 
bronchitis alone. Among other complications and sequelae of bronchial 
dilatation may be enumerated haemoptysis, as a consequence of ulcer- 
ation of the bronchial mucous membrane ; pyo-pneumothorax, which may 
be produced by the rupture of the bronchial cavity into the pleural sac ; 
pulmonary emphysema ; inflammation of the lungs ; inflammations of 
the joints, probably caused by purulent absorption ; cerebral abscess ; 
meningitis; suppuration within the spinal cord; tuberculosis; and 
amyloid degeneration of the abdominal organs. 

Diagnosis. Bronchiectasis may be easily recognized when the 
characteristic expectoration appears in association with the symptoms 
of the existence of a cavity. From tuberculous cavities within the lungs 
it may be distinguished by the history of the case, by the locality of 
the dilated bronchus in the lower or middle lobe rather than in the 
apex of the lungs, and by the absence of tubercle-bacilli in the sputa. 

From the contents of an encysted pyo-pneumothorax that is discharged 
through the lungs, the expectoration in bronchiectasis may be distin- 
guished by the absence of the odor of sulphuretted hydrogen in the 
discharges, and by the absence of cholesterine and hoematoidin. Pul- 
monary gangrene may be distinguished from putrid bronchitis affecting 
a dilated bronchus, by the presence of broken-down lung tissue in the 
gangrenous expectoration. 

Prognosis. The prognosis is very unfavorable, by reason of the 
numerous complications and sequela? to which the disease is liable. 

Treatment. Three principal objects must be kept in view in the 
treatment of bronchiectasis : 1. The dilated bronchus must be emptied 
by means of expectorants or emetics (p. 444). 2. Diminution of secre- 
tion must be attempted by the inhalation of sprays impregnated with 
oil of turpentine or carbolic acid (2 per cent.). Astringents have been 
frequently employed, but with very little result. 3. Disinfection of 
the contents of dilated bronchial cavities must be effected by the inlia- 



DISEASES OF THE TRACHEA AND BRONCHI. -. 53 

The cause of the obstruction, when intrusion of foreign bodies is ex- 
cluded, must be determined by the history of the patient, and by inves- 
tigation of the organs which lie in the vicinity of the bronchi. 

Prognosis. The prognosis is almost always unfavorable, though 
perhaps less so in cases of syphilitic origin. Foreign bodies sometimes 
are removed accidentally through the acts of coughing, laughing, sneez- 
ing, or vomiting, even after they have been lodged for years in the air- 
passages. 

Treatment. The treatment must be adapted to each case in accord- 
ance with general principles. Foreign bodies may sometimes be removed 
by inverting the patient, or by the administration of emetics, or by 
tracheotomy and the introduction of forceps into the bronchi. Syphi- 
litic cases require a specific treatment with mercurials and iodide of 
potassium. Dyspnoea without pronounced symptoms of asphyxia may 
be relieved by the cautious use of opiates. 

Bronchial Asthma. 

Symptoms. Bronchial asthma is characterized by the occurrence 
of paroxysms of dyspnoea which have their origin in a spasmodic con- 
dition of the muscles. During the interval between successive paroxysms 
the patient may enjoy excellent health. 

An asthmatic attack may be ushered in without warning, or it may 
be preceded by symptoms of depression, disordered digestion, gaseous 
distention of the stomach and bowels, and other symptoms which indi- 
cate the existence of slight and transient catarrhal inflammation of the 
gastro-pulmonary mucous membranes. Female patients sometimes ex- 
perience a recurrence of asthma in connection with the menstrual 
epoch. Many patients suffer from a recurrence of a paroxysm on the 
slightest provocation — such as a change of sleeping-rooms, even in the 
same house. Other patients experience a similar result after indulgence 
in certain articles of food or drink. Sometimes the occurrence of the 
paroxysms occurs with such regularity as to suggest their dependence 
upon malarial infection. 

The asthmatic paroxysm frequently occurs during the middle of the 
night ; the patient is awakened out of deep sleep, and starts up out of 
bed, driven by the impossibility of breathing to the nearest window, 
which is thrown open, leaning far out and pressing his chest against 
the window-sill in the eagerness of his efforts to obtain fresh air. If 
unable to leave the bed, he finds himself compelled to remain in a 
sitting posture, or to lean forward with his hands placed upon the 
nearest support. The skin is cool, the pulse is accelerated, small, and 
tense. Inspiration is slow and laborious, while expiration is still more 
difficult and prolonged. The countenance expresses the horrible dis- 
tress which the patient experiences ; the veins become prominent, the 
lips and the surface of the body exhibit an increasing cyanosis, perspi- 
ration covers the skin with cold and clammy sweat, the accessory mus- 
cles of respiration are called into a high state of activity by the con- 
traction of the abdominal muscles ; the inferior portions of the thorax 
are drawn downward during inspiration, the recti muscles project like 



454 DISEASES OF THE ORGANS OF RESPIRATION. 

solid bars of wood, involuntary evacuations of urine and feces some- 
times occur. If the attack be considerably prolonged, symptoms of 
venous congestion involve the brain, and there may be indications of 
delirium, or of a tendency to convulsive movements in the muscles of 
the extremities. Auscultation discovers, throughout the whole extent 
of the lungs, numerous rales and rhonchi, which are especially noisy 
during the act of expiration, so that the entire cavity of the thorax is 
literally converted into a " chest full of whistles." Vesicular breathing 
is either absent or rendered inaudible by the noisy rales that accompany 
respiratory movements. Percussion indicates no loss of resonance ; in 
fact, the thoracic cavity becomes more resonant, and emits a deeper tone 
than under normal conditions. The limits of pulmonary resonance extend 
downward from one to three intercostal spaces lower than usual, and 
the area of cardiac dulness is diminished by the inflation of the anterior 
border of the left lung. The heart sounds are, also, less audible for 
the same reason. 

As the paroxysm subsides, the bronchial rales become moist and less 
noisy. Dyspnoea and other urgent symptoms subside, and the attack 
usually terminates with a moderate amount of expectoration. 

Microscopical investigation of the sputa indicates the presence of 
minute spiral filaments which appear to be derived from exudation into 
the smaller bronchial passages. Associated with these filaments are 
various epithelial cells that have been exfoliated from the mucous mem- 
brane of the bronchi, and numerous round cells which exhibit various 
stages of degeneration. With this debris occur numerous acicular crys- 
tals, the so-called asthma crystals, regarding the nature and origin of 
which there has been much discussion without very positive results. 

As to the nature of the asthmatic process, it is apparent that it con- 
sists in an irritation of the nervous system, involving chiefly the terminal 
fibrils of the pneumogastric nerve, by which spasmodic contraction of 
the bronchial muscle is effected. This may exist as a reflex conse- 
quence of disordered conditions in distant organs, or it may be the direct 
result of temporary excitement of the nerve itself. The occurrence of 
catarrhal disorders in persons who are predisposed to asthma, operates 
as a means of increasing the previous excitability of the nervous appa- 
ratus. The undoubted relation that exists between asthmatic attacks 
and other nervous disorders, and their alternation with paroxysms of 
nervous disturbance, such as angina pectoris or hemicrania, argue in 
favor of the neurotic character of the disease. 

Etiology. Tivo forms of bronchial asthma have existence. The 
first is dependent upon diseases of the central nervous system ; while 
the second is the result of reflex excitation of the pneumogastric nerve. 
With regard to the first form, considerable doubt may be connected with 
the theory that asthma is the direct result of cerebral disease ; what is 
more certain is that direct disturbances of the pneumogastric nerve are 
not unfrequently followed by asthmatic paroxysms. In this way the 
existence of tumors by which the nerve is compressed in the neck, or 
in the thorax, operate powerfully, in many instances, to excite the dis- 
ease. Only when these directly impinge upon the trunk or upon the 
branches of the nerve can they be considered as direct causes of asthma. 



DISEASES OF THE TRACHEA AND BRONCHI. 455 

More frequent are the cases in which irritation arising from disease in 
distant organs is propagated to the central origin of the pneumogastric, 
and is thence communicated to the muscles in the bronchial wall. In 
this way the existence of irritation in the nasal mucous membrane, such 
as occurs in hay fever, and after inhalation of ipecacuanha powder, or 
kindred substances, may produce an asthmatic paroxysm. Diseases of 
the nasal mucous membrane, such as polypi, adenoid growths, chronic 
tumefaction of the turbinated processes ; chronic pharyngitis ; enlarge- 
ment of the tonsils ; diseases of the heart ; dyspeptic conditions, chronic 
inflammations of the digestive organs, constipation, and the presence of 
worms in the intestines ; diseases of the ovaries and of the uterus ; the 
state of pregnancy ; and chronic nephritis, may any one of them prove 
efficient excitants of reflex asthma. 

Besides these forms, and, probably, in many cases connected with 
them, are cases of asthma that are undoubtedly dependent upon intoxi- 
cation of the blood with various poisonous substances. Such are many 
cases of asthmatic paroxysm which occur in the course of chronic renal 
disease, or as a consequence of gout or rheumatism. Lead and mer- 
curial poisoning are also sometimes causes of toxic asthma. The 
disease occurs most frequently between the twentieth and fortieth years 
of life, though children and old people sometimes suffer with it. More 
frequentl}' it is observed among men than among women. Delicate 
and unhealthy people, especially those of rachitic or tubercular predis- 
position, are particularly inclined to the disease. Those forms which 
depend upon catarrhal conditions of the bronchial membranes are more 
likely to occur during unfavorable seasons of the year, and in cold 
damp localities. 

Pathological Anatomy. Since the disease, so far as the bronchi 
are concerned, is a functional disorder, pathological changes are not 
conspicuous, unless bronchial catarrh may exist as a complication. 
Secondary changes may follow repeated attacks, producing emphysema 
and atelectasis of the lungs. 

Diagnosis. The recognition of bronchial asthma seldom presents 
any difficulty, since no other disease is characterized by paroxysms of 
expiratory dyspnoea accompanied by excessive inflation of the pul- 
monary air cells. Other forms of dyspnoea are characterized by inspi- 
ratory obstruction of the respiration, or by a simple feeling of breath- 
lessness without any evident local cause in the respiratory organs. 

Prognosis. Despite the alarming appearance of the patient during 
a paroxysm of asthma, the prognosis is not unfavorable. Death very 
rarely occurs during an attack, since any considerable accumulation of 
carbonic acid in the blood and in the tissues necessarily produces re- 
laxation of the muscular spasm by which the bronchioles are occluded ; 
and, thus, air immediately finds access to the alveolar passages, with 
prompt relief of dyspnoea. When the disease occurs among young 
children they usually recover permanently as they grow up. 

Treatment. The treatment of the asthmatic paroxysm, if depen- 
dent upon acute indigestion, should be commenced by the administration 
of a prompt emetic (apomorphine -^ of a grain hypodermically). After 
the stomach has been evacuated, or, as the first step in the treatment, if 



456 DISEASES OF THE ORGANS OF RESPIRATION". 

gastric embarrassment do not exist, thirty grains of chloral hydrate 
should be given in a wineglassful of water. This dose may be repeated 
within half an hour, if sufficient relief be not already procured. A 
hypodermic injection of morphine and atropine should also accompany 
the first dose In this way the paroxysm will generally be conducted 
to a speedy termination. The use of other narcotics and emetics gives 
less satisfactory results. When reflex irritation proceeds from the naso- 
pharyngeal mucous membrane, a favorable result may be obtained by 
pencilling the parts with a ten per cent, solution of cocaine. Inhalations 
of chloroform, nitrite of amyl, ether, and other similar substances have 
been practised with more or less success. Lately, French authors 
recommend inhalations of pyridine, of which a teaspoonful may be 
poured into a saucer and held before the face. German authors, of 
course, look with special interest upon the failures which follow this 
method of treatment. 

Inhalation of medicated fumes from burning paper that has been 
dipped in solutions of arsenic and saltpetre, and the use of powders 
containing saltpetre and dry stramonium leaves, and burned in a large 
container so as to create a dense smoke, oftentimes affords considerable 
relief. The ordinary pastiles are too small to produce much benefit. 
Some persons derive great relief from simple measures, like the smok- 
ing of a cigar, or the sucking of ice, or the use of peppermint drops, or 
common nervous stimulants. Many other remedies have their advo- 
cates, but none compare with those which been have first indicated. 

For the prevention of the paroxysm, the constitutional predisposition 
of the patient, and the present state of his health, should be carefully 
studied. Local diseases must be cured, if possible : gastro-intestinal 
disorders must be guarded against ; gout and rheumatism must be sup- 
pressed ; malarial poisoning and other infective conditions must be 
obviated. Excellent effects are often obtained from the long-continued 
use of iodide of potassium (five to ten grains three times a day). This 
drug is the basis of the majority of the proprietary remedies for asthma 
that possess any special value. The inhalation of a one per cent, solu- 
tion of common salt, repeated several times a day, is recommended for 
the solution of asthma crystals. The use of electricity, by the method of 
central galvanization, is of some service in cases that are complicated 
by nervous predisposition. Sometimes it happens that nothing will 
insure a patient against recurrent paroxysms excepting removal from 
the locality in which he has resided. Favorable effects may be thus 
obtained bv a chancre of residence to the mountainous regions in the 
central portions of the continent. During the winter months it is 
desirable to seek a dry, warm, and sunny locality, such as may be found 
in many parts of Texas, Southern California, and Mexico. In every 
case particular attention must be directed to the clothing, diet, and 
habits of the patient. 

Inflammation of the Tracheo-bronchial Lymph Glands. 

The lymph glands which are connected with the air passages are 
subject to acute inflammation and enlargement as a consequence of 



DISEASES OF THE LUNGS. 457 

inflammation involving those air passages. Chronic inflammation, 
syphilis, leukaemia, and pseudoleukemia are sometimes attended with 
considerable swelling of the lymph glands, which may then exercise 
deleterious pressure upon the neighboring bronchi, or upon the oesopha- 
gus and the pneumogastric nerves. The degree of tumefaction may 
sometimes be so great as to produce a notable dulness on percussion 
over the upper portion of the sternum. The degree of compression 
exerted upon neighboring organs may interfere considerably with 
respiration, and may excite a most harassing cough, or vomiting. The 
movement of the heart may be disturbed, and symptoms of obstructed 
circulation may become apparent. The subsidence of such swelling is 
itself sometimes the cause of additional disturbances in the neighboring 
organs, as may be observed when an enlarged gland has become 
adherent to the wall of the oesophagus. During the subsequent con- 
traction that accompanies the reduction of the glandular swelling, the 
oesophageal wall is at that point drawn outward, and a pouch or 
diverticulum is formed. Glandular tuberculosis sometimes leads to 
suppuration, with subsequent evacuation of pus into neighboring cavities 
or vessels. In this way sudden asphyxia may be produced by the 
rupture of the abscess into the trachea or into a large bronchus. If 
rupture does not follow the process of suppuration, the imprisoned pus 
may become caseated, or, finally, calcified. 

Malignant diseases of the glands are attended with even more exten- 
sive enlargement, and with corresponding symptoms of pressure and 
encroachment upon neighboring organs. 



CHAPTER V. 

DISEASES OF THE LUNGS. 

Pulmonary Hemorrhage — Haemoptysis. 

Etiology. Haemoptysis signifies the presence of blood in the 
sputa of expectoration. This may proceed from many causes, hence 
the spitting of blood is to be regarded as a mere symptom, and not as 
a disease. Blood may thus be discharged from the larynx, from the 
trachea, the bronchi, or the parenchyma of the lungs ; but, since 
hemorrhage from the larger air passages is a rare event, it may be 
safely assumed that in the majority of cases haemoptysis is the result 
of inflammatory or ulcerative processes in the bronchi or pulmonary 
substance. 

Bronchial hemorrhage may tinge the sputa with streaks of blood in 
cases of severe bronchitis. It also occurs in connection with the forma- 
tion of casts in the bronchi. Valvular diseases of the heart that are 
attended with obstruction of the circulation through the lungs may 
occasion an oozing of blood from the bronchial mucous membrane. 
The same event may be observed as a consequence of bronchiectasis, or 



453 DISEASES OF THE ORGANS OF RESPIRATION. 

of putrid bronchitis, when the mucous membrane has been eroded and 
the bloodvessels are laid bare. 

Violent bodily exertion which necessitates inordinate action on the 
part of the respiratory organs : their irritation by the inhalation of 
irritating gases, e. g.. chlorine, ammonia, excessively hot or cold air, 
etc., and the intrusion of foreign bodies, are not uncommon causes of 
haemoptysis. 

The occurrence of pulmonary consumption is sometimes attended 
by hemorrhage from the bronchial vessels as a consequence of 
degenerative changes that are dependent upon the tubercular process. 
In this way haemoptysis may become one of the earliest symptoms of 
pulmonary tuberculosis, before any physical signs can be discovered in 
the lungs. 

In like manner bronchial hemorrhage may result from the various 
infective diseases in which a tendency to hemorrhage is manifested. 
Renal and hepatic diseases by which the blood is overcharged with 
refuse matter, and certain dyscrasiae, such as scurvy, haemophilia, and 
purpura, may be accompanied by bronchial haemoptysis. The sup- 
pression of customary discharges of blood from other organs, such as 
may occur in persons who are liable to epistaxis, bleeding piles, or 
profuse menstruation, may lead to the occurrence of a species of 
vicarious hemorrhage from the bronchial mucous membrane. 

Similar hemorrhage may be due to the reduction of atmospheric 
pressure that occurs during balloon ascensions or mountain climbing. 

Hemorrhage from the parenchyma of the lungs may result from 
actual rupture of the bloodvessels, or from the passage of red blood- 
corpuscles through the capillary walls. It occurs, most frequently, 
during the course of pulmonary consumption ; in the earlier stages of 
the disease it generally assumes the character of a capillary oozing, 
but during the later course of the disease, after the formation of cavi- 
ties, it may result from the rupture of arteries that have been thus 
exposed. 

Abscess and gangrene of the lungs may also occasion an erosion of 
the walls of arteries that have been reached by the process, with conse- 
quent escape of blood in the form of a copious hemorrhage. In like 
manner tumors and parasites in the lungs (Distomum Ringeri, Filaria, 
Gregarina pulmonalis, and Echinococcus) may become causes of 
hemorrhage. 

Acute inflammation of the lungs is attended with haemoptysis by 
which the sputa acquire their characteristic color. The rupture of an 
aneurism into the lungs will of course be followed by abundant hemor- 
rhage. Heart diseases frequently cause embolic processes in the lungs, 
with formation of infarcts and hemorrhages in those organs. Sometimes 
the intruded embolus can be discovered, but in certain cases hemorrhage 
seems to be the result of capillary degeneration rather than of obstruc- 
tion. Actual obstruction is frequently dependent upon a disease of the 
mitral valve, with dilatation of the right side of the heart, and the 
formation of thrombi in its cavities. Obviously, however, similar re- 
sults may follow the formation of thrombi in any of the veins that 
communicate more or less directlv with the right auricle. 



DISEASES OF THE LUNGS. 459 

Nervous diseases and disorders are sometimes accompanied by haemo- 
ptysis ; this is notably the case among hysterical patients. 

Haemoptysis occurs most frequently during the twenty years that 
follow the age of puberty ; that is, during the period when pulmonary 
tuberculosis is most frequently observed. 

Pathological Anatomy. Bronchial hemorrhage is accompanied 
by a swollen, reddened, and congested appearance of the mucous mem- 
brane. It is not easy to discover any definite point of escape through 
which the blood enters the bronchi, since the hemorrhage generally con- 
sists of a capillary oozing. Sometimes the mucous membranes are pale, 
as a consequence of collapse after excessive hemorrhage. The air cells 
are frequently filled with blood, and blood corpuscles may be traced in 
their course through the epithelial lining of the cells into the inter- 
stitial connective tissue. 

When hemorrhage takes place into the pulmonary parenchyma, there 
may be excessive accumulation of blood and broken-down lung tissue, 
constituting what is termed pulmonary apoplexy. When hemorrhage 
takes place through the walls of a cavity, the point of rupture may be 
frequently discovered in the wall of an exposed artery. The arrest of 
hemorrhage under such circumstances is effected by the formation of a 
thrombus by which the vessel is occluded. When capillary hemorrhage 
occurs into the substance of the lung, it is not always easy to discover 
where the blood made its escape ; a dark-red mass remains surrounded 
by inflated and emphysematous air cells. This is the hemorrhagic in- 
farct. After a time such blood corpuscles as have not been removed 
by absorption become disintegrated, and their pigmentary detritus re- 
mains in the alveolar and interfundibular septa. Hemorrhagic infarcts 
that are produced by emboli or thrombi derived from the heart, may be 
recognized by their conical form, of which the broad base is directed 
toward the periphery of the lung, while the point is directed toward 
its roots. In the majority of cases the process of infarction occurs in 
the lower lobe of the right lung, which receives blood most readily from 
the right ventricle. Under ordinary circumstances embolic infarcts are 
absorbed, leaving behind a dark pigmented mass of indurated connec- 
tive tissue ; but if an infective embolus or thrombus finds its way into 
the lungs it may originate inflammation, suppuration, or even gangrene. 
Symptoms. A small amount of blood may find its way into the air 
passages without exciting notable symptoms, or death may occur from 
sudden asphyxia in connection with copious hemorrhage before blood 
can appear externally ; but, generally, the occurrence of haemoptysis is 
observed among patients who are already the victims of pulmonary or 
cardiac disease. 

It often happens that before the appearance of blood in the sputa 
there is complaint of a peculiar, salty taste in the mouth, or a sensa- 
tion of heat and upward pressure along the course of one of the larger 
bronchi or the trachea. Sometimes the sputa are but slightly discolored 
with blood ; in other cases the mass consists of bright-crimson blood, 
mixed with frothy mucus. In still other cases it may gush out of the 
mouth and nose as if an artery had been severed. If any considerable 
portion be swallowed, vomiting is often excited, and the patient both 



460 DISEASES OF THE ORGANS OF RESPIRATION. 

spits and vomits blood. The quantity thus evacuated is sometimes 
sufficient to produce death in a very short space of time, either as a re- 
sult of asphyxia or as the direct consequence of hemorrhage (acute 
anaemia). 

Sometimes haemoptysis is characterized by only a single discharge ; 
in other cases it recurs at short intervals for several days. When de- 
pendent upon malarial infection, the recurrence is periodical unless 
arrested by large doses of quinine. 

The color of the sputa varies with the amount of blood and the 
length of time since its evacuation from the bloodvessels. Bloody sputa 
are generally frothy, and of a bright-scarlet color ; but if blood has 
been retained for any length of time in a cavity, it becomes coagulated 
and exhibits a dark color, hence after copious haemoptysis it is not un- 
common to witness the occasional discharge of dark clots which are 
coughed up for two or three days after the original hemorrhage. 
Haemoptysis that accompanies pneumonic inflammation, or gangrene, 
or hemorrhagic infarction, often presents a rusty color like that of 
tobacco-juice or prune-juice. In chronic inflammation like that which 
characterizes putrid bronchitis, when the quantity of blood is scanty, 
and when the blood corpuscles have undergone considerable disintegra- 
tion, the color of the sputa resembles that of clay or mud. 

Slight haemoptysis produces no physical signs of change within the 
thorax. If the air cells are filled with blood, fine rales may become 
audible ; and, if any considerable territory is thus obstructed, dulness 
on percussion may be perceived, with other symptoms of pulmonary 
consolidation. 

Afebrile movement is sometimes observed during the absorption of 
blood that has been poured out of the capillaries into the air passages 
and air cells, especially if associated with chronic inflammatory condi- 
tions and putrefaction within the respiratory organs. Acute inflamma- 
tion is sometimes excited by hemorrhagic processes ; and in this the 
pleural surfaces that cover a hemorrhagic infarct are very liable to 
share. 

Diagnosis. Haemoptysis must be distinguished from pharyngeal 
or laryngeal hemorrhage, and from bleeding tvithin the cavity of the 
mouth. Careful investigation of these cavities will facilitate diagnosis. 
Haemoptysis must also be distinguished from hcemate metis. Hemor- 
rhage from the stomach is consequent upon diseases of that organ which 
are attended with ulceration. Blood from such a source is usually 
coagulated, dark in color, and possesses an acid reaction as a conse- 
quence of the presence of gastric juice. Gastric hemorrhage is also 
frequently followed by black and tarry stools consisting largely of 
altered blood. Haemoptysis is usually preceded by diseases of the heart 
or lungs. The blood that is ejected is bright and frothy, with an alkaline 
reaction ; if dark and clotted, it is owing to a prolonged sojourn in the 
bronchi or in the pulmonary cavities. Only when previously swallowed, 
will it be thrown up by the act of vomiting. In like manner dark, 
clotted blood, with an acid reaction, that has been vomited from the 
stomach, may sometimes find its way into the larynx and trachea, and 
be subsequently ejected by the act of coughing. Blood from the nasal 



DISEASES OF THE LUNGS. 461 

and aural cavities may, in a similar manner, find its way into the air 
passages or into the stomach, and create temporary confusion in the 
matter of diagnosis, but careful observation and consideration of the 
previous history should soon remove all obscurity regarding the nature 
of the hemorrhage. Microscopical observation of the sputa, and the 
discovery of tubercle bacilli, or the appearance of parasitic structures, 
may sometimes serve to explain certnin difficult cases. Physical exam- 
ination of the chest will, of course, demonstrate the presence of morbid 
products within the pulmonary organs. 

Prognosis. The prognosis is not necessarily unfavorable, for slight 
cases of haemoptysis are often followed by complete and permanent re- 
covery. Copious hemorrhage may sometimes terminate life suddenly ; 
but, as a rule, the appearance of blood is merely a symptom of some 
other disease, upon which the prognosis will chiefly depend. 

Treatment. Prophylactic treatment is based upon a recognition of 
the predisposing causes of hemorrhage, and upon the avoidance of such 
exposure to cold or violent exertion as may occasion haemoptysis. 
Severe cough may be moderated by the use of narcotic remedies (p. 
445); diseases of the heart require the cautious use of digitalis. The 
occurrence of peripheral diseases associated with the formation of 
thrombi, e.g., femoral phlebitis, requires perfect rest and the avoidance 
of manipulations or movements by which thrombotic fragments may be 
introduced into the course of the circulation. 

For the arrest of actual haemoptysis, the patient must be placed 
quietly in bed, with as little disturbance as possible in the way of physical 
examination and movement of the body. Food should be restricted to 
cold liquids ; ice, and ice-water, may be given as desired. Fifteen 
minims of the fluid extract of ergot should be injected hypodermically 
twice or three times a day. If the air passages be obstructed with blood 
so as to cause danger from asphyxia, expectorant mixtures, or stimulant 
emetics, may be administered. Astringents and saline remedies are 
often very efficacious ; a teaspoonful of common salt or of saltpetre will 
sometimes be sufficient to arrest a moderate hemorrhage. Lead and 
opium pills, tannic acid, gallic acid, the perchloride of iron, etc., have 
all been used with advantage. Pulverization of the same substances, 
in a two or five per cent, solution, is often employed for purposes of 
inhalation, but this method is sometimes followed by inflammation of 
the lungs. The stimulant effect of balsamic remedies sometimes pro- 
duces a favorable result. 

R . — Tr. benzoin, co Tl\xxx. 

S. — On sugar, every half-hour. 

H . — Balsam, copaib. ^ 

Syr. picis liquid. V aa ^ij. 

Alcohol. J 

Spt. aether, nitros. ....... 3jss. 

Aq. menth. pip ^ iv. — M. 

S. — A tablespoonful twice a day. 

The mineral acids (ten drops in four ounces of water every two hours) 
are frequently useful ; of these, aromatic sulphuric acid should be pre- 



462 DISEASES OF THE ORGANS OF RESPIRATION. 

ferred. The patient must be cautioned to suck the liquid through a 
glass tube, and to rinse the mouth with cold water, in order to prevent 
the effects of the acid upon the teeth. 

External counter-irritation with dry cups, sinapisms, and irritating 
liniments, is often of great service ; sometimes the application of 
cloths wrung out of hot water produces a better effect than can be 
obtained from the ordinary method of applying ice-bags to the thoracic 
wall. 

Plethoric patients may be benefited by venesection, or by the applica- 
tion of leeches. Haemoptysis that is dependent upon suppression of 
the menses or of hemorrhoidal discharges, may be promptly arrested by 
the application of a half-dozen leeches to the anus, or to the insides of 
the thighs just above the internal condyles. 

A very useful method in many cases consists in the application of 
ligatures or tourniquets about the limbs near their juncture with the 
body, by which sufficient pressure may be exerted to retain a consider- 
able quantity of blood in the vessels of the extremities without com- 
pletely arresting the circulation. In this way the degree of blood 
pressure within the pulmonary vessels can be considerably diminished. 
The operation may be continued without risk for an hour, and should 
be repeated as often as beneficial. 

Alveolar Emphysema — Emphysema Pulmonum Alveolare. 

Pathological Anatomy. Dilatation of the air cells of the lungs 
may occur for a short time without the production of emphysema, but 
its frequent repetition or its long persistence leads to a permanent 
expansion of the infundibular and alveolar spaces, with atrophy of their 
septa. These changes may be limited to a small portion of the lungs ; 
they may be unilateral or bilateral, and may occupy an extensive por- 
tion of the lungs. The affected portions appear pale, bloodless, and 
dry ; and they crepitate on pressure between the fingers. The enlarged 
air cells are distinctly visible, and sometimes reach great size through 
the . absorption of intervening septa The anterior surfaces and the 
median border of the lungs, especially in the upper lobes, exhibit the 
highest degree of alveolar dilatation. The thorax is round and dis- 
tended; the lungs remain expanded when the chest is opened; pleuritic 
adhesions are not uncommon; there is catarrhal inflammation in the 
smaller bronchi ; the heart is concealed from view by the overlapping 
borders of the emphysematous lungs, and its right side is often con- 
siderably dilated and filled with blood ; the vence cava? are also dis- 
tended ; the diaphragm is depressed by the voluminous lungs ; the 
liver exhibits evidences of venous hyperemia and enlargement if death 
has taken place at a comparatively early period, or of contraction if 
life has been sufficiently prolonged ; the spleen is somewhat enlarged, 
and shows hypertrophy of its connective tissue ; the g astro-intestinal 
mucous membrane is swelled and slightly inflamed ; the hcemorrkoidal 
veins are frequently dilated ; the kidneys also share in the universal 
venous distention that follows dilatation of the right side of the 
heart. 



DISEASES OF THE LUNGS. 463 

Etiology. Pulmonary emphysema is generally encountered in 
advanced life, more frequently among men than among women. 
Climate and weather that favor the occurrence of cough are predis- 
posing causes of the disease. 

The most common cause of emphysema is found in disorder of the 
respiratory organs. Chronic catarrh of the smaller bronchi is the usual 
exciting cause, but any other condition by which the bronchi may be 
constricted can lead to the development of alveolar emphysema. Under 
such circumstances all movements that necessitate extraordinary eifort 
on the part of the respiratory organs become active agents in the 
dilatation of the air cells. 

Emphysema of the lungs that is produced by the foregoing causes is 
termed substantial emphysema. Besides this form of the disease a 
variety may exist that is developed as a consequence of more or less 
complete occlusion of certain portions of the lungs, so that adjacent 
portions which still receive air are subjected to an inordinate degree of 
expansion. This form of the disease is termed vicarious emphysema, 
and it occurs in connection with effusion into the pleural cavities, ex- 
cessive dilatation of the heart, thoracic aneurisms, tumors, etc. Two 
forms of emphysema may sometimes occur in the same pair of lungs, 
since one does not exclude the other. 

Symptoms. The loss of elasticity that is experienced by the pul- 
monary tissue as a consequence of atrophy and dilatation of the walls 
of the air cells, diminishes the respiratory power of the lungs, pro- 
ducing what is termed expiratory insufficiency. The degree of this 
insufficiency may be readily estimated by the aid of a pneumatometer. 
The ventilation of the lungs will be proportionately hindered, and thus 
will be created a corresponding sensation of the want of air. 

The dilatation and atrophy of the alveolar walls occasion a consider- 
able reduction in the number of the capillary vessels and of the surface 
available for aeration of the blood ; hence another cause for the sensa- 
tion of want of air. 

Reduction in the number of capillary vessels that are available for 
the pulmonary circulation produces increased pressure in the pulmonary 
artery ; consequently, the right side of the heart must become dilated 
and hypertrophied, if the pulmonary circulation is to be maintained. 
If, however, the cardiac muscle fails, the phenomena of obstructed cir- 
culation will immediately appear, and this condition will be inevitably 
followed by its usual consequences and termination. 

During the earlier period of the disease dyspnoea is only felt after 
unusual exercise, or during the occurrence of bronchial catarrh, or 
whenever a slight chronic catarrh is temporarily aggravated. Under 
such circumstances asthmatic paroxysms are not uncommon. 

The physical signs of pulmonary emphysema become more con- 
spicuous as the disease progresses. (Fig. 100.) Inspection indicates 
that the thorax has assumed a more cylindrical form, with an increase 
of depth between the sternum and the spinal column. The intercostal 
spaces are widened and slightly depressed. The supra-clavicular fossse 
are sometimes considerably prominent, and bulge outward in the act 
of coughing. The movements of respiration are accelerated and 






: iseases 



HE ORGANS 7 RESPIRATION. 



shallow, as if the thorax wall were always maintained in an inspiratory 
position. The auxiliary muscles of inspiration, notably those in the 
neck, become : :-phied. The la :. 

tende the surface :: the bodv exhibits a more or less cyanotic 

:r :-:t.\:-.\:::t. 

Fig. 100. 







Pa yields s aei is :ion of limited res i itory movement in the 

thoracic wall. Vocal fremitus is reduced, the cardiac impulse can be 
only very faintly or not at all perceived, on ae: : ~he imperfect 

::tive power if the emphysematous lung tissue that is intruded 
between the he :he thoracic wall. Sometimes the hypertrophied 

right ventricle can be felt beneath the ensifbrm carta] ■ 

Pi yields i note that is more resonant than normal, and 

indie:.:— nsiderahle depression of the diaphragm. The upper surface 
of the liver is found at the level of the eighth rib, or Ion 
lving at the upper border of the seventh rib in the right mammary 
line. Cardiac dullness is greatly reduced, or entirely abolish ^ 

•_•>. the I :der of the lung is found on a line with the 

twelfth dorsal vertebra, and there is very little change in the level of 
the diaphragm during the movemeL'« :::n. With the I 

a spirometer. ole reduction of the vital capacity of the I 

may be demonstnl 

Is zreat. if not complete, loss of 1 ilar mur- 

mur, the expiratory sound being prolonged and of low pitch. The 
hear: - Is - L in intensity and the diastolic pulmonary 

sound situated . pressure in the pulmonary 

artery. S "lie murmurs sometimes exisl - : ana?mia 

or of a degenerated condition of the cariiac musd sequence 

of auriculo-ventricular valvular insufficiency, dependent upon cardiac 
dilatation. 

Besides the vesicular sounds which are characteristic of alv-r 
emphysema there may signs of intercurrent complications, such as 



DISEASES OF THE LUNGS. 465 

rhonchi and rales that indicate the presence of bronchial inflamma- 
tion. 

The duration of the disease may be very tedious, sometimes continu- 
ing from childhood to an advanced age. Death usually results from 
cardiac insufficiency that may be dependent either upon fatty degener- 
ation, or upon some unusual and excessive task that is laid upon an 
already overburdened organ. The evidences of retarded circulation 
then appear, and death follows. Sometimes the lungs become oedema- 
tous, or cerebral hemorrhage may occur. 

It occasionally happens that during a violent fit of coughing, or some 
other form of excessive exertion, a rupture of the emphysematous lung 
may take place, thus orignating a pneumothorax, if the air enter the 
pleural cavity, or a general, subcutaneous emphysema if it escape into 
the interstitial lung tissue. Pulmonary inflammation, or embolic pro- 
cesses dependent upon cardiac disease, or hemorrhage in connection with 
severe bronchial inflammation, may occur as complicating diseases. 

The belief that emphysema and pulmonary consumption or valvular 
disease of the heart are incompatible, is not without foundation, though 
exceptions to the general rule are not very uncommon. 

Diagnosis. A slight degree of emphysema may exist without 
recognition through the ordinary physical signs. The existence of 
expiratory insufficiency ;md want of air, which cannot be accounted for 
in any other way, should lead to a suspicion of pulmonary emphysema. 

Acute dilatation of the air cells may be distinguished from emphy- 
sema by the recent development of physical signs, and by their rapid 
disappearance when the cause is removed. Pneumothorax may be dis- 
tinguished by its almost uniformly unilateral occurrence, and by the 
metallic resonance of the sounds that are elicited by auscultation and 
percussion. Congenital hypertrophy of the lungs, though exhibiting 
unusual downward extension of pulmonary resonance, may be dis- 
tinguished by the normal character of the respiratory movements. 

Prognosis. So far as speedy death is concerned, the prognosis in 
pulmonary emphysema is not unfavorable ; but the opposite is true in 
respect of a permanent cure. Severe pulmonary or cardiac diseases add 
greatly to the gravity of the situation. 

Treatment. Prophylactic treatment necessitates the avoidance of 
those causes by which bronchial inflammation and pulmonary or cardiac 
diseases can be either induced or aggravated. The treatment of such 
conditions, if already existing, forms the most important part of the 
prophylactic and symptomatic treatment of emphysema. 

Favorable results may theoretically be obtained through the methods 
of pneumatotherapy, since expiratory insufficiency is relieved by expira- 
tion into a vessel that contains air under reduced pressure. By this 
method the intra-vesicular air is, as it were, sucked out of the dilated 
alveolar spaces. Conversely, the respiratory process is facilitated by the 
inspiration of compressed air, which forces its way more readily through 
the obstructed bronchioles into the air cells. Through a combination 
of the two methods — by inhaling air from a vessel in which it is sub- 
jected to increased pressure, and by exhaling into a partial vacuum — 
good results are obtained. This exercise should be repeated, two or 

30 



DISEASES J: THE _ ?: >> A X 5 O* RESPIRATION. 

three tim — for a period which maybe gradually lengthened from 

ten minutes, at firs:, to an hour or more, as the patient becomes accus- 
tomed to the treatment 

The use of digitalis when the heart begins to grow weak, expectorants 
when the bronchi::- ises a troublesome cough, careful attention to 
hygienic surroundings, often a change :f climate — all the— have their 
place in certain cases. 

Interlobular Emphysema — Emphysema Pulmonum Interlobular. 

Pathological Ahatomy. Ink lobular empl - -' 

consists in the entrance of air into the meshes of the interfundibular 
and interlobular connective tissue. This implies a previous rupture of 
pulmonary air cells. This usually occurs in the anterior portion of the 
npper lobe of the lungs. The air that escapes into the connective tissue 
r Is its ~ay to the peripheral surfaces of the lungs, where it becomes 
diffused thi nigh the subpleural tissue of the pulmonary lobules, forming 
visible air-bobbles which may be displaced by pressure, causing their 
movement along the lobular I ; ries. In like manner air finds its 

way through the interstices of the connective tissue along the blood- 
vessels and bronchi as far as the root of the lungs, whence it may be 
still further diffused throughout the mediastinal spaces and the sub- 
cutaneous tissue : the neek and greater part of the body. 
Etiology. Kupture of the air cells of the lungs may be prod 
rect violence such - is experienced when the thorax is crushed 
jr the wheels : vehicle, : by excessive inflation of the lun^-- 
the endeavor to produce artificial respiration in newborn children 
who do not breathe. It may also occur is a ■:• : ^sequence of excessive 
muscular effort during temporary closure or the glotti- such is happens 
ighing, -training, or extraordinary use :: the voice. It. 
consequently, sometimes occurs in connection with any form of obstruc- 
tion :: the ail assages. 

SYMPTOMS. This form of pulmonary emphysema can seldom be 
recog : ^ n g life- unless it may have attained to the production of 

is mphysema. Before acceptance of the diagnosis in such 
- nsibility : the escape of air through the rupture of the 

bronchi, trachea, laryr. sophagus, must be exclude!. Pneumo- 

m only be ascribed to this after exclusion of all other can- - 
T: Subcutaneous emphysema that results from alv v 

rupture requires no special treatment, since the air is spontaneously 
h Cough and liscomfort must be relieved by the use of nar- 
cotic remedies. 

Pulmonary Collapse — Atelectasis Pulmonum. 

(sequence of the absence 
of air and other substances from the alveolar cavities. This may 
be produced — (1) by the pei - sf he ante-natal condition in 

tain porl f the lun^s. as may - metimes bservi I after difficult 

or premature delivery S times the respii . ges are ob- 



DISEASES OF THE LUNGS. 467 

structed by the inhalation of mucus during the first act of inspiration, 
and thus certain portions of the lung fail to receive air ; in other cases 
the strength and excitability of the infantile tissues is deficient through 
imperfect development, consequently the entrance of air into the 
bronchi does not sufficiently excite the respiratory centres in the 
medulla oblongata. (2) Obstructive atelectasis is produced as a conse- 
quence of bronchial obstruction which prevents the dependent portion 
of the lung from obtaining a proper supply of air. The alveolar spaces 
become, therefore, more or less completely emptied through absorption 
of their gaseous contents. This form of the disease most frequently 
occurs in connection with the capillary bronchitis of children, as may 
be observed in the course of measles, whooping-cough, or bronchial 
diphtheria. In like manner the intrusion of blood or other foreign 
bodies into the bronchi may lead to collapse of the dependent pul- 
monary territory. In rare instances the same result may follow 
compression of the bronchus by a tumor. (3) Portions of the pul- 
monary tissue may undergo collapse as a consequence of direct pressure 
exerted by accumulations of air or liquid in the pleural cavities, or by 
the development of any other intra-thoracic disease or deformity which 
may exert continuous pressure upon the lungs or upon any portion of 
them. (4) Marasmic collapse of the lungs is sometimes developed in 
the course of long and wasting diseases, most frequently in typhoid 
fever, and in the chronic diarrhoea of children. In such cases, pro- 
gressive failure of muscular power and diminution of the irritability of 
the respiratory centres in the medulla oblongata concur with prolonged 
maintenance of the recumbent position to prevent sufficient expansion 
of the lungs. Under such circumstances, certain portions of the 
vesicular structure fall into a state of collapse. 

Pathological Anatomy. Very seldom does any considerable 
portion of a single lobe or of the entire lung become collapsed ; it is 
usually restricted within particular lobular limits. Congenital 
atelectasis most frequently occurs in the lower portion and anterior 
border of the lung. Those forms of the disease which depend upon 
obstruction or marasmus, principally affect the lower and posterior 
portions of the lungs. Collapse that is produced by compression of 
the lung substance is located in correspondence with the source of 
pressure. 

Atelectasis is usually manifested in the peripheral portions of the 
lungs. When dependent upon bronchial obstruction it exhibits the 
form of a cone, with its base at the pleural surface and its apex at the 
point of obstruction. Collapsed structures appear shrunken and of a 
dark-red, brown, or gray color. Artificial inflation of the lungs pro- 
duces distention of the sunken portion, followed, in recent cases, by 
restoration of its normal color. 

The collapsed tissues do not crepitate on pressure, but have a tough, 
sometimes leathery, feeling ; and on incision, air-bubbles do not 
appear with the fluid discharge that escapes from the air cells and 
bronchi. Fragments of the tissue sink when placed in water. 

It not unfrequently happens that the collapsed portions of the lungs 
become surrounded by an emphysematous zone (vicarious emphysema), or 



468 DISEASES OF THE ORGANS OF RESPIRATION. 

they may become hypersemic (carnification), and may pass into a con- 
dition of actual inflammation. Instead of inflammation, the process of 
exudation may become limited to the accumulation of serum and debris 
in the air cells, producing a close resemblance to the substance of the 
spleen (splenification). 

Symptoms. Congenital pulmonary collapse may be best observed 
at the time of birth. Instead of the vigorous outcry and active move- 
ment by which the newborn child announces his arrival, the occurrence 
of atelectasis is indicated by insufficient and intermittent respiration, 
indisposition to movement of the limbs, cyanosis, feeble and frequent 
pulse, and inability to nurse. Death often occurs after spasms and 
convulsions. 

The occurrence of pulmonary collapse at a later period of life is indi- 
cated by respiratory insufficiency, with the physical signs that indicate 
the absence of air from a circumscribed portion of the lungs. An 
especially characteristic sign is presented by the diminution of dulness 
and crepitation which may occur after deep inspiration and change of 
position, by which air is made to enter the collapsed alveolar spaces. 
Partially collapsed portions of the lung may yield a tympanitic sound 
on percussion. 

Diagnosis. Pulmonary collapse must be differentiated from pneu- 
monia, hemorrhagic infarction, and pleurisy. From the first it may 
be distinguished by alterations of the percussion sound that are effected 
by change of position and by deep inspiration. 

Hemorrhagic infarctions are characterized by the occurrence of 
bloody expectoration, and by the coexistence of conditions which favor 
embolism. Pleurisy may be recognized by the horizontal limitation 
of dulness, and by the diminution or absence of vocal fremitus. 

The characteristic history in each case will often aid in clearing up 
a doubtful diagnosis. 

Prognosis. The prognosis is so far dependent upon the amount of 
collapse, and upon the causes by which it has been produced, that no 
general rule can be laid down. Each case must be judged by itself. 

Treatment. Prophylactic treatment is applicable to that class of 
cases which occur in the course of long-continued and exhausting dis- 
eases. Such patients should be frequently placed in different positions, 
and should receive such therapeutic care as will obviate the tendency 
to depression of the respiratory centres. Congenital atelectasis requires 
the ordinary measures for the removal of slimy obstructions from the 
air passages. Frequent changes of position, and gentle irritation of the 
skin by friction and by alternate applications of warm and cold water, 
are usually sufficient to effect the expansion of the lungs ; though 
sometimes the condition of collapse persists for many days, or even 
longer. The occurrence of atelectasis in the course of diseases at a 
later period of life calls for especial attention to predisposing disorders, 
and to the promotion of respiration by the use of expectorants, stimu- 
lants, tonics, etc. 



DISEASES OF THE LUNGS. 469 

Pulmonary Hypostasis — Hypostasis Pulmonum. 

Pathological Anatomy. In all cases of protracted disease asso- 
ciated with weakness of the heart and great physical exhaustion there 
is danger of blood-stasis in the posterior and inferior portions of the 
lungs, if the patient remain long in the recumbent position without 
change of attitude. The dependent portions of the lung become dark in 
color, and, on section, appear to be saturated with a dark, sticky, 
bloody fluid. The capillary vessels in the walls of the air cells are dis- 
tended, and project into the alveolar spaces which are occupied by the 
fluid portion of the blood that is transuded. A certain number of white 
and red blood-corpuscles and the remains of the alveolar epithelium are 
mixed with the transudate. The microscopical appearances, therefore, 
considerably resemble those that accompany catarrhal inflammation ; 
but they are unattended by fever or by the other symptoms of inflam- 
mation. The general appearance and consistence of the lungs recalls 
that of an enlarged and softened spleen, hence the term splenification 
that is applied to this condition. 

Etiology. Pulmonary hypostasis occurs most frequently as a con- 
sequence of infective fevers, notably during the later stages of typhoid 
fever, when the patient lies inert and feeble, in the same position for a 
long period of time. Other diseases of an exhausting character, espe- 
cially when they occur at an advanced age, or are of a character to 
interfere seriously with the movements of the lungs, are liable to be 
attended by the development of hypostasis. 

Symptoms. The symptoms of blood-stasis in the lungs are often 
overlooked by reason of the severity of the primary disease in connec- 
tion with which it is developed. Frequently the symptoms of increasing 
asphyxia afford the earliest indication of pulmonary obstruction. Per- 
cussion indicates dulness over the lower portion of both lungs, if the 
dorsal position has been long maintained. Respiratory sounds are 
diminished, and crepitant rales are audible, unless the air cells are 
completely occupied by the liquid transudate. If air has been com- 
pletely expelled from the affected portion, the physical signs of pneu- 
monia are present. 

Diagnosis. From pulmonary collapse it is difficult to distinguish 
pulmonary hypostasis. In like manner it is often difficult to distinguish 
it from inflammation of the lungs, unless one is acquainted with the 
previous history and course of the disease. From oedema of the lungs 
it may be distinguished by circumscribed dulness on percussion, and 
by a less extensive development of moist rales throughout the lungs. 

Prognosis. The prognosis depends upon the nature of the predis- 
posing disease and condition of the patient. 

Treatment. The occurrence of pulmonary hypostasis should be, so 
far as possible, avoided by attention to the position of the patient, who 
must be moved in bed as often as every two or three hours. Weakness 
of the heart must be anticipated and obviated by the use of cold baths 
and antifebrile remedies, associated with large doses of alcohol. If 
other cardiac stimulants are needed, camphor, musk, ammonia, strych- 
nine, or capsicum may be administered. 



470 DISEASES OF THE ORGANS OF RESPIRATION. 

(Edema of the Lungs — (Edema Pulmonum. 

ETHOLOGY. (Edema of the lungs signifies a saturation of the pulmonary 
tissues and air cells -with a serous liquid derived from the capillary vessels. 
Acute oedema maybe developed in the space of a few minutes, and may 
complete its course within a few hours. Oh 'una may continue 

for a longer period of time. Transudation may occur in a limited por- 
tion of a single lung, or it may quickly occupy the entire lung on both 
sides of the thorax. The independent existence of pulmonary oedema 
is a very rare thing, though its rapid development may occur after ex- 
posure to slight causes, or even without any apparent exciting cause, 
when a predisposition to the event already exists as a consequence either 
of cardiac, or pericardial, or nn:d % or any other disease by which 
blood-stasis within the lungs may be favored. Especially is this the 
case when dilatation and hypertrophy of the right ventricle are asso- 
ciated with an enfeebled condition of the left ventricle, as in eases :: 
mitral stenosis. It is probable also that the occurrence of cachectic 
conditions, such as may be originated by the development if : ;••//•. or 
tuberculosis, or chronic nephritis, may occasion a modification of the 
capillary walls by which transudation into the air cells and surrounding 
tissues is facilitated. The existence of circumscribed inflammation in 
any portion of the lungs is frequently followed by the development of 
oedema in the adjacent portions of "Lose organs. 

Pathological Anatomy. On removal of the thoracic wall, the 
lungs appear enlarged, and do not collapse. Pressure with the finger 
upon the surface of the lungs causes a depression that persists for a 
little time in proportion to the loss of elasticity by the pulmonary con- 
nective tissue. On section of the lungs, the air cells and smaller 
bronchi appear to be filled with a serous, frothy liquid which may be 
either transparent or more or less tinged with blood. The previous 
occurrence of icterus gives it a yellowish color, and other die - 
conditions which have imparted to the lungs an unusual tinge, give also 
to the ^edematous fluid a similar tint. 

Symptoms. Pulmonary cedc/na obviously interferes with the aeration 
of the blood in the lungs, consequently the symptoms are largely those 
of progressive asphyxia Respiration becomes accelerated and laborious. 
The integuments are cyanosed. the mind becomes clouded, muscular 
spasms may occur, and death finally results from suffocation. 

In the early stage of the disease there is usually a very 

f thin, frothy liquid, frequently resembling s-xipsuds : 
sometimes these frothy sputa are more or less tinged with blood. They 
contain very little mucin, and a few white corpuscles and epithelial 
cells from the alveolar spaces As the strength of the patient fails, the 
air pass _ - cease to discharge their contents, and the trachea and 
bronchi are filled with a bubbling liquid which can be no longer expec- 
torated, but remains to impede respiration and to accelerate the develop- 
ment of asphyxia. 

Percussion indicates little change from the normal sounds. Auscul- 

ers all forms of moist rales and rhonchi which occupy the 

bronchi throughout the affected portion of the lungs. In severe and 



DISEASES OF THE LUNGS. 471 

extensive cases they may be heard over the whole extent of the thorax, 
and are audible at a distance from the patient, constituting the " death- 
rattle " which is developed during the later stages of the disease. 

Prognosis. The prognosis in cases of pulmonary oedema is always 
very grave, not only in consequence of the resulting asphyxia, but by 
reason of the diseases which may exist as its predisposing cause. Death 
sometimes so rapidly follows its development that the disease has been 
often called pulmonary apoplexy. 

Treatment. Since the occurrence of pulmonary oedema is generally 
dependent upon cardiac failure, it is desirable to guard the heart against 
any of the possible causes of exhaustion, especially during the course 
of acute or chronic diseases that are liable to such termination. Symp- 
toms of oedema should be at once followed by the administration of 
cardiac stimulants. Hot foot-baths and sinapisms should be extensively 
applied. Expectoration should be facilitated by the use of stimulant 
expectorants, such as squills and senega. The aromatic spirits of am- 
monia may be given in half-drachm doses every fifteen minutes. An 
excellent cardiac stimulant may be formed by the association of camphor 
and capsicum with benzoic acid. 

B.—Pulv. gum. camphor.") u 

Fulv. capsici. J 

Acid, benzoic 9ijss.— M. 

Div. in chart, no. x. S. — One powder every two hours. 

Strychnine (gr. -^V hypodermically every four hours) is very useful 
when cyanotic discoloration of the lips appears. Emetics should gen- 
erally be avoided, on account of their depressing influence, which favors 
the progress of asphyxia If these remedial measures fail to give relief, 
great benefit is often obtained from venesection, by which the over- 
distended right ventricle is relieved and the general circulation of blood 
is aided. If the abstraction of blood should seem undesirable, somewhat 
similar results may be obtained by ligation of the extremities. 

Catarrhal Inflammation of the Lungs— Pneumonia Catarrhalis. 

Catarrhal inflammation of the lungs consists in the extension of 
acute catarrhal inflammation from the bronchioles into the air cells of 
the lungs. For this reason the disease is frequently termed broncho- 
pneumonia. It usually occupies circumscribed portions of the lungs, 
hence the term lobular pneumonia, by which it has been frequently 
known. 

Etiology. Catarrhal pneumonia is always a secondary disease, 
frequently occurring as a complication of the infective diseases, or, as 
a consequence of the extension of capillary bronchitis into the alveolar 
passages and air cells. It is, therefore, frequently observed among 
feeble and cachectic children, especially during the period of dentition, 
which acts as a predisposing cause of disease involving the respiratory 
apparatus. It is also a common event among old people, and among 
those who have previously experienced the disease, especially when ex- 
posed to cold, damp weather, such as occurs during the early and later 
months of winter. 



472 DISEASES OF THE ORGANS OF RESPIRATION. 

Among the exciting causes of catarrhal pneumonia must be reckoned 
the intrusion of foreign bodies into the smaller bronclri ; but it is 
probable that these act chiefly as vehicles for the transport of the 
parasitic agents by which inflammation is excited, notably streptococcus 
pyogenes and staphylococcus pyogenes aureus et albus. Occurring in 
association with recognized infective diseases, it is probable that the 
action of their contagia serves to prepare the way for the proliferation 
and specific effects of these microorganisms. 

Pathological Anatomy. Catarrhal pneumonia occurs in the 
form of disseminated inflammatory areas which are sometimes very 
numerous, though seldom contiguous. These inflammatory indurations 
may vary in size from the head of a pin to a walnut. Sometimes a 
number of such distinct areas become confluent and constitute a 
genuine lobar pneumonia. 

The favorite seat of catarrhal inflammation is in the subpleural tis- 
sues, in the posterior and inferior portions of the lungs near the spinal 
column, upon one or both sides of the thorax. In these localities the 
substance of the lungs feels as if occupied by indurated masses, which, 
upon section, exhibit a dark-red color, and contain no air in the 
alveoli. The incised surface is smooth and shining, without the 
granular appearance that is visible on incision of a lung that has 
undergone fibrinous inflammation. The adjacent bronchi contain a 
muco-purulent secretion which sometimes appears to have undergone 
coagulation and degeneration, so that it can be pressed out of the tubes 
in the form of a cylindrical, semi-solid, cheesy mass. 

It is not an uncommon event to find other portions of the lungs in 
a state of collapse, indicated by the fact that they can be inflated 
through the bronchi, and that detached portions will float in water, 
showing that the vesicular structures still contain air. The anterior 
borders of the lungs have sometimes undergone compensatory inflation, 
so that the heart may be quite concealed from view. The pleural 
surfaces and the bronchial lymph glands almost always participate in 
the inflammatory process, though not to the extent of serous or puru- 
lent effusion into the pleural cavities. 

Microscopical investigation indicates dilatation of the capillary vessels 
in the walls of the air cells, with serous exudation into the alveoli, 
which are occupied by a mixture of detached epithelial cells, blood 
corpucles, and serum, together with the parasitic microorganisms which 
excite the inflammatory process. 

Symptoms. So frequently is catarrhal pneumonia associated with 
other diseases that its symptoms cannot always be dissociated from 
those of the primary disease. Its duration is always exceedingly 
variable ; acute cases being terminated within one or two weeks, while 
subacute cases generally last for one or two months, and chronic 
forms may continue much longer. The febrile movement by which 
it is accompanied is subject to great variations of intensity and persist- 
ence. Remissions, intermissions, and relapses are not uncommon. As 
a general rule the fever presents a daily morning remission, and its 
termination is gradual, instead of critical. The temperature in acute 
cases is high, so much so that its persistent elevation above 102° F. in 



DISEASES OF THE LUNGS. 473 

cases of apparent bronchial catarrh should lead to the suspicion of an 
associated broncho-pneumonia. The movements of the pulse and of 
respiration are greatly accelerated. Often each expiration is termi- 
nated by a moan, and respiration may be irregular and intermittent. 
The act of coughing is often attended with pain, and pressure upon the 
chest frequently causes indications of suffering. In severe cases 
inspiratory dilatation of the nostrils and retraction of the intercostal 
spaces and floating ribs may be observed. Dulness on percussion, with 
increase of vocal fremitus, occur only when an area of inflammation is 
at least as extensive as the pleximeter that overlies it. It is over the 
posterior part of the lungs, on one or both sides of the thorax, that dulness 
becomes evident. Sometimes it acquires a tympanitic character through 
collapse and relaxation of the lung substance in the immediate neigh- 
borhood of the seat of inflammation. 

Auscultation discovers crepitant and sibilant rales, but bronchophony 
and bronchial breathing are only perceptible when the area of inflamma- 
tion is considerably extended. 

Expectoration is usually absent in young children and old people. 
Such sputa as are discharged are muco-purulent and, sometimes, tinged 
with blood. 

Recovery is gradual and often interrupted by relapses that are caused 
by the lighting up of new centres of inflammation. Fatal cases are the 
result of progressive exhaustion, or cardiac paralysis, or asphyxia. 
Among children Cheyne-Stokes respiration, or muscular spasms, not 
infrequently terminate the course of the disease. 

In severe cases various septic complications may occur. Cutaneous 
abscesses, or even gangrene have been sometimes observed, and catarrhal 
inflammation of other organs may coexist. The serous membranes ot 
the body may also become involved in the inflammatory process ; and, 
finally, tuberculosis may invade the weakened tissues. 

Diagnosis. A positive diagnosis is not always possible in cases of 
catarrhal pneumonia. It may be distinguished from pulmonary collapse 
by its greater persistence, and by its independence of changes of posi- 
tion or respiration. From the infiltration of tuberculosis, it may be 
distinguished by the absence of tubercle bacilli in the sputa. From 
fibrinous pneumonia it may be distinguished by the absence of rusty 
sputa ; by its variable duration ; and by the existence of multiple foci 
of inflammation. 

Prognosis. The prognosis is always very grave. Under unfavor- 
able circumstances the disease is almost inevitably fatal ; and, at best, 
about one-third of the cases fail of recovery. 

Treatment. The patient should be placed in a spacious, well- 
ventilated apartment, in which the temperature is constantly maintained 
at 70° F., and the air is continually moistened with the spray of warm 
water. The surface of the body should be sponged with tepid water 
every morning and evening, and fever may be combated by the admin- 
istration of acetanilide or phenacetine in doses of two to ten grains 
according to the age of the patient. Pain may be relieved by warm 
poultices applied to the chest. The occurrence of bronchial rales is an 
indication for the use of expectorants, or of emetics if there be great 



474 DISEASES OF THE ORGANS OF RESPIRATION. 

obstruction of the air passages (p. 444). If a tendency to asphyxia be- 
come apparent, warm baths and the administration of strychnine will 
be found useful. Showering the occiput with a stream of cold water, 
or sprinkling the chest with cold water while the rest of the body is 
immersed in a warm bath, have been recommended for the purpose of 
arousing the respiratory centres in the medulla oblongata. In all cases 
the diet should consist of broths, milk, eggs, and a moderate allowance 
of alcoholic stimulants. 

Fibrinous Pneumonia — Pneumonia Fibrinosa. 

Fibrinous pneumonia is an infective disease characterized by a febrile 
movement, and by a local inflammation through which the air cells of 
one or more lobes of the lungs are filled with a fibrinous exudation 
which may also involve the bronchi and infundibular passages. 

Etiology. The active agent in the production of pneumonia is a 
microorganism, the so-called jmeumococcus. (Fig. 101.) It is probable 

. Fig. 101. 



Iff til' : ^j|- w- 

Diplococcus pneumoniae. (Hallo peat:.) 

that several allied species exist which possess the power of exciting 
pneumonic inflammation, and it is not improbable that the varieties of 
inflammation which have been observed are due to corresponding varia- 
tions in the character of the bacterial cause. The same parasite is en- 
dowed with the power of exciting inflammation upon the serous mem- 
branes in other parts of the body, e. g., the pleura, the pericardium, 
the peritoneum, and the meninges of the brain. The greater proclivity 
of the inferior lobe of the right lung to pneumonia, is supposed to de- 
pend upon the fact that the right bronchus is larger than the left ; 
hence, infected air carries the contagion more readily into the right 
lung, where the action of gravity causes its principal accumulation in 
the lower lobe. The inferior lobe of the left lung stands next in the 
order of liability to infection, then follow the middle and upper lobes of 
the right lung, and last of all, the upper lobe of the left lung. The 
influence of cold in the production of pneumonia is probably restricted 
to its action as a predisposing cause by which the resistance of the pul- 
monary tissue is reduced, so that the bacterial contagion is left free to 
exert its deleterious influence. 

Fibrinous pneumonia occurs much more frequently among men than 
among women, and it attacks old people rather than those in earlier 
life. Enfeeblement of the health, delicacy of organization, and previous 
experience of the disease also act as predisposing causes. 

The occurrence of pneumonia as an epidemic disease has often been 
observed in certain localities, notably in places where unhygienic sur- 
roundings and overcrowding favor the prevalence of infective disease ; 



DISEASES OF THE LUNGS. 475 

thus it has been observed as a local epidemic in barracks, jails, alms- 
houses, and in the habitations of the poor. The season of the year and 
the character of the weather exert great influence upon the prevalence 
of the disease ; it is more common during cold, damp weather in the 
latter part of winter and in early spring than during the dry, warm 
months of the year. 

Secondary pneumonia sometimes develops during the course of the 
eruptive fevers, and during the final stage of chronic diseases, like 
Bright's disease, diabetes, cancer, etc. 

Pathological Anatomy. The course of fibrinous pneumonia may 
be divided into three stages : congestion, hepatization, and resolution. 
These stages are not sharply defined, but may be found concurrently 
developed in different portions of the same lung. (1) The stage of 
congestion is characterized by great accumulation of blood in the affected 
portion of the lung, which is considerably swelled, pits on pressure, and 
is more or less destitute of air in the alveolar spaces. Microscopical 
examination discovers the usual vascular changes that occur in inflam- 
mation. The epithelium of the air cells is largely exfoliated, degener- 
ated, and mixed with extravasated white and red corpuscles of the blood 
floating in a sticky, albuminous fluid that is exuded from the capillary 
vessels. (2) The stage of hepatization is characterized by complete 
absence of air from the alveolar spaces, and their occupation by the 
products of exudation which have undergone coagulation. The sub- 
stance of the lung is converted into a firm, resistant mass, which sinks 
in water, and does not bleed on incision. The incised surface presents 
a granular appearance like that which is presented by a similar section 
of the liver. The color of the hepatized lung is at first a dark red, 
which is gradually replaced by a brownish-red, and, finally, by a gray 
color (gray hepatization). (3) The stage of resolution is characterized 
by fatty degeneration of the products of exudation. The inflamed por- 
tion of the lung is occupied by a puriform fluid which can be expressed 
from the smaller bronchi, and which, by careful exposure to a current 
of water, may be washed out of the air cells without injury to their 
structure. A considerable portion of the resolving exudate is thrown 
off by expectoration, but the greater part is removed by absorption 
through the lymphatic channels. With the completion of this process 
the alveolar epithelium becomes fully regenerated, and the normal 
function of the part is renewed. 

The pleural surface that covers the inflamed portion of the lung 
usually exhibits a moderate degree of fibrinous inflammation. The 
larger bronchi manifest a state of catarrhal inflammation, but the 
bronchioles are occupied by the fibrinous exudation that fills the air 
cells. Occasionally the larger bronchi are similarly obstructed. The 
bronchial glands are swelled and hyperaemic. The right side of the 
heart is distended with blood which is loosely coagulated, while the left 
side is empty. The muscular substance of the organ appears flaccid, 
and sometimes gives evidence of granular or fatty degeneration. The 
abdominal organs exhibit a condition of venous hyperemia. The liver 
is enlarged with blood; the spleen is also swelled and softened in a 
manner that is characteristic of infective diseases. The kidneys fre- 



476 DISEASES OF THE ORGANS OF RESPIRATION. 

quently exhibit the characteristic changes of catarrhal inflammation. 
The mucous membrane of the intestinal canal is in a similar condition, 
and the vessels of the brain appear distended with blood. 

Symptoms. The length of the period of incubation in pneumonia 
is unknown, and is probably of variable duration. Different observers 
have estimated it all the way from two days to three weeks. 

Fibrinous pneumonia usually commences suddenly with a severe 
chill and pain in the affected side that are succeeded by fever, with the 
usual symptoms of burning heat, dry skin, suffusion and injection of the 
eyes, circumscribed redness of the cheeks which is sometimes visible 
only upon the side that corresponds to the inflamed lung. The tongue 
is thickly covered with a gray or yellowish coat, and in severe cases 
becomes dry and brown, sometimes fissured and bleeding. The pulse 
and the respiration are accelerated. There is pain and uneasiness in 
the affected portion of the chest, increased by cough and deep respira- 
tion. The urine is scanty, high colored, acid, and often contains a 
small quantity of albumin ; the chlorides are present in diminished 
quantity. The bowels are constipated, and the feces are dry and dimin- 
ished in amount. The sputa are at first colorless, tenacious, and very 
slightly frothy, very soon becoming darker from admixture with the 
coloring matter of the blood, and assuming the characteristic rusty 
color. 

After the expiration of twelve or twenty-four hours the physical 
signs of exudation begin to appear. At first, they indicate the pres- 
ence of liquid in the air cells ; then succeed the evidences of pulmonary 
consolidation ; and, finally, during the stage of resolution, renewed 
evidences of liquid in the air cells and bronchioles are apparent. The 
physical signs, therefore, vary with the course of the disease, and cor- 
respond with the changes that are produced by the processes of exuda- 
tion and absorption 

Inspection indicates an abridgment of the respiratory movements 
upon the affected side of the thorax. The patient frequently lies upon 
that side, so as to restrict, as far as possible, all movement of the 
inflamed lung. Palpation discovers an increased vocal fremitus over 
the seat of inflammation as soon as the air cells become filled with the 
coagulated exudate by which the conductivity of the lung substance is 
augmented. In this way the waves of sound that originate in the 
larynx and are propagated through the trachea and the bronchi are 
readily transmitted to the surface of the thorax. It must not be for- 
gotten that vocal fremitus is normally more perceptible upon the right 
side of the thorax than upon the left, and that its transmission to the 
surface may be temporarily arrested by any transient obstruction of the 
principal bronchus upon the affected side. In such cases, however, the 
disappearance of fremitus is not permanent, and its normal develop- 
ment is renewed so soon as the bronchial obstruction has been removed 
by a paroxysm of cough. 

Extensive infiltration of the lun^ causes a notable increase in the 
circumference of the affected side. 

During the stages of hypenemia and resolution, percussion yields a 
resonant sound, which is replaced by complete dulness during the stage 



DISEASES OF THE LUNGS. 477 

of hepatization. The tympanitic quality of the percussion note is due 
to a somewhat flaccid condition of the walls of the air cells during the 
period when their contents are yet gaseous. Occasionally the " cracked- 
pot " sound is audible during percussion, when the mouth is opened. 
If the inflamed portion of the lung be covered to a considerable depth 
by healthy, vesicular tissue, dulness may fail to be elicited by percus- 
sion ; and if the seat of inflammation is superficial, it must occupy a 
space of at least three inches in diameter, with a thickness of an inch, 
before it can yield distinct dulness in response to percussion. 

Auscultation during the stages of hyperemia and of resolution dis- 
covers the existence of fine, crepitant, inspiratory rales over the 
affected portion of the lung ; they are most audible near the end of the 
inspiratory act. These rales are produced by the movement of the 
alveolar walls in contact with the sticky exudation that partially fills 
the air cells. During the stage of hepatization, crepitant rales disap- 
pear, but sibilant rales may be heard in the bronchi. Bronchial 
breathing is also audible, and bronchophony is increased in consequence 
of the superior conductivity of the consolidated lung substance. Some- 
times segophony becomes audible. 

The appearance of the sputa possesses great diagnostic importance ; 
at the commencement of the disease they are colorless, and so tenacious 
that they will not flow out of an inverted spittoon ; they are often 
streaked with blood, but, presently, they assume a characteristic rusty 
color, which is observed in scarcely any other disease, and is caused 
by the presence of pigment derived from the red blood- corpuscles ; the 
total quantity that is expectorated is not great, rarely exceeding eight 
or ten ounces in the twenty-four hours. Besides the blood corpuscles, 
round cells, alveolar and bronchial epithelium, pneumococci, and 
various microorganisms of inflammation and suppuration, the sputa 
contain numerous fibrinous casts of the bronchioles and infundibular 
passages, similar to those which are formed in certain cases of fibrinous 
bronchitis. During the period of resolution, the sputa assume a yel- 
lowish color, and, finally, present the characteristics of an ordinary 
muco-purulent expectoration. 

The temperature varies, during the course of fibrinous pneumonia, 
between 102° and 106° F. The fever is continued, and usually 
terminates by crisis between the fifth and eighth days. (Fig. 102.) 
The temperature falls in the course of a few hours, sometimes reaching 
a subnormal level. In certain cases, crisis is preceded by consider- 
able increase in the severity of all the symptoms. Sometimes the 
critical fall of temperature is followed by an immediate renewal of 
fever and high temperature, which again subsides critically after a 
period of two or three days. Occasionally, fever continues in a remit- 
tent form for a week or more after the normal critical point has been 
passed, and then rapidly subsides by lysis. (Fig. 103). 

The commencement of crisis is usually attended by copious perspira- 
tion, followed by deep, and refreshing sleep. The urine becomes more 
abundant, and deposits a considerable quantity of reddish-brown sedi- 
ment of urates. 

The course of the pulse follows that of the temperature ; at first it is 



478 



DISEASES OF THE ORGAXS OF RESPIRATION. 



full, strong, and incompressible. Among adult patients it usually 
beats from 100 to 120 times a minute ; a rate of 130 to 140 per 
minute indicates great severity and danger. Young children frequently 
exhibit a pulse of 200 beats per minute. During crisis the pulse is 
sometimes depressed below the normal figure: if it be retarded during 
the height of the fever, it is probable that some complication exists in 
connection with the heart or with the brain ; irregularity and inter- 
mission of the pulse are indicative of cardiac debility. 



Fig. 102. 



Fig. 103. 





Crisis. Temperature in lobar pneumonia. 
Sudden crisis on eighth day: pseudo-crisis 
on fourth day. (Wuxderltch). 



Lysis. Temperature in broncho-pneu- 
monia. Gradual fall extending over four 
days. (Wuxderlich). 



The movements of respiration are accelerated during the period of 
fever, reaching 30 or 40 respirations every minute ; among children 
they may run as high as 100 per minute. 

Pain about the level of the nipple, upon the affected side, is a very 
common symptom. It is increased by cough and by movement of the 
body, and is. probably, occasioned by the pleuritic inflammation that 
accompanies pulmonary infiltration. Consciousness usually remains 
undisturbed throughout the course of the disease. Sometimes there is 
slight delirium, and sleep may be disturbed by dreams, or may be 
entirely prevented by a distressing cough. An eruption of herpes 
frequently occurs about the lips of the patient: it is sometimes observed 
elsewhere upon the face, or upon the surface of the body. Since it is 
rarely present in cases of typhoid fever, its eruption may assist the 
diagnosis in doubtful cases. Other exanihematous eruptions have been 
observed, such as erythema, roseola, urticaria, pemphigus, or purpura. 
Miliaria usually appears during protracted perspiration. 

In addition to the ordinary form of fibrinous pneumonia above 
described, various departures from the typical species have been 
observed. Sometimes the attack is aborted within a few hours after the 
appearance of characteristic symptoms, before the complete develop- 
ment of the stage of hepatization. Such cases are described as aborted 
pneumonia. Sometimes the fever lingers for two or three weeks, and 
terminates gradually by lysis, while the physical signs of consolidation 



DISEASES OF THE LUNGS. 479 

remain for several weeks longer. Sometimes the process of exudation 
and infiltration pursues an erratic and serpiginous course, reminding 
one of the progress of erysipelas, with which, in fact, it may be occa- 
sionally associated. In such instances the spleen becomes extraordi- 
narily tumefied. Again, this erratic form of pneumonia may occur in 
association with acute inflammatory rheumatism, giving occasion for a 
belief in its rheumatic origin and character. In certain cases the early 
symptoms of pneumonia may recur at regular periods that are in- 
duced by malarial infection. Such cases may sometimes be promptly 
relieved by large doses of quinine ; but sometimes a fatal termination 
cannot be prevented. It rarely happens that pneumonia runs its course 
without the manifestation of febrile symptoms. In other cases the dis- 
ease assumes an asthenic form which indicates a high degree of infection. 
It is characterized by great prostration and cardiac debility ; there is 
high fever, nervous irritability, delirium, or the development of an 
apathetic, typhoid condition. Exudation occurs frequently in the upper 
lobes of the lungs, or upon both sides of the chest. Expectoration may 
be absent, or of a distinctly hemorrhagic character. Considerable albu- 
minuria is generally observed. The skin frequently assumes a jaundiced 
hue. Abscess or gangrene of the lungs not unfrequently occur ; also 
other inflammations, such as pericarditis, meningitis, gastro-enteritis, 
etc., and death is the usual termination of the disease. This form of 
pneumonia is frequently known as typhoid, malignant, or bilious pneu- 
monia. It is more often observed in warm weather, and in southern 
latitudes, than during the winter months. 

The chill with which pneumonia is usually introduced is generally 
absent when the disease attacks children. It is replaced by a period of 
somnolence, or by vomiting, or by convulsions which so commonly 
characterize the commencement of other infective diseases among chil- 
dren. Nervous symptoms are often observed during its course, and the 
termination is usually gradual instead of being abruptly concluded by 
crisis. The indications derived from characteristic sputa are usually 
absent, because children and old people almost always swallow their 
sputa. 

Pneumonia among old people is ordinarily characterized by an 
insidious invasion, and by the rapid development of a tendency to pros- 
tration and cardiac debility. Intemperate people, besides a predisposi- 
tion to the occurrence of pneumonia, manifest a very marked tendency 
to the development of delirium tremens and other evidences of complete 
nervous exhaustion. The disease is liable to be complicated with other 
consequences of chronic alcoholism. 

As a result of the tendency, in certain cases, to a generalization of 
the exciting cause of pneumonia, other diseases are not unfrequently 
associated with inflammation of the lungs. Bronchitis and pleurisy 
thus frequently coexist with the original disorder. In like manner 
endocarditis or pericarditis may be set up through the invasion of the 
cardiac apparatus by infective pneumococci and pyogenic germs. The 
intercurrence of icterus may be caused by a simple catarrhal inflamma- 
tion of the duodenum, by which the outflow of bile into the intestine is 
prevented ; or it may be produced by interference with the circulation 



480 DISEASES OF THE ORGANS OF RESPIRATION. 

of blood in the liver ; or as a consequence of the extension of inflam- 
mation from the right lung and diaphragmatic pleura to the hepatic 
peritoneum. The occurrence of jaundice often affords an unfavorable 
augury, since bile pigments and biliary acids are powerful heart poisons 
which greatly diminish the vigor of that organ. The presence of bile 
pigment in the sputa gives them a grass-green color which is valuable 
as a diagnostic indication 

Albuminuria occurs in about one-half of the cases of pneumonia : it 
is the result of irritation or inflammation of the kidneys with the pneu- 
monic contagion, and it speedily disappears as soon as that is elimi- 
nated. 

The occurrence of delirium tremens in alcoholic patients, and the 
manifestation of nervous symptoms in connection with fever, have 
already been mentioned. It sometimes happens that meningitis may 
occur as a result of infection of the meninges by pneumococci and pus 
microbes as they diffuse themselves throughout the body. The menin- 
geal inflammation follows the pulmonary disease after the lapse of a few 
days. Death may occur speedily, before the occurrence of any con- 
siderable meningeal exudation ; or it may be delayed until purulent 
effusion has been fully developed. 

Like other infective diseases, pneumonia may be accompanied or 
followed by septic complications, multiple abscess, gangrene, purulent 
inflammation of the parotid gland, pulmonary abscess, and, occasionally, 
by paralysis. Chronic interstitial inflammation of the lungs, pulmonary 
tuberculosis, and insanity, have also been observed after pneumonia. 

Diagnosis. Among the most characteristic evidences of fibrin on s 
pneumonia must be ranked the occurrence of rusty sputa, though, for 
the reasons that have been previously mentioned, sputa of any kind 
are. frequently absent. The occurrence of saffron-colored sputa indi- 
cates the commencement of resolution ; grass-green sputa accompany 
icterus ; a liquid, frothy, prune-juice sputum indicates a tendency to 
pulmonary oedema. In the absence of sputa, pneumonia may be fre- 
quently inferred from the course and critical termination of the fever, 
which must also be taken into consideration in estimating the value of 
the physical signs, since crepitant rales occur in cedema and in hem- 
orrhagic infarcts of the lungs ; while sonorous rales and increase of 
vocal fremitus and bronchophony, together with dulness on percussion, 
and bronchial breathing, are developed whenever the alveolar spaces 
are occupied by any substance that excludes air. In pleurisy with 
effusion, dulness, bronchial breathing, aegopheny, and sonorous rales 
may be present ; but vocal fremitus is diminished instead of being in- 
creased as it is in pneumonia. The upper limit of dulness. moreover, 
is horizontal, or nearly so. in whatever position the patient is placed. 
In doubtful cases experimental puncture of the thorax will indicate the 
presence of fluid if pleurisy exist. 

The occurrence of cerebral or abdominal symptoms may sometimes 
excite hesitation with regard to the nature of the disease. Roseolous 
eruptions favor the diagnosis of typhoid fever, which may be rendered 
certain by the discovery of typhoid bacilli in the stools, or in blood 
taken from the rose spots. The occurrence of herpes is an argument 



DISEASES OF THE LUNGS. 481 

in favor of pneumonia. In doubtful cases the lungs should be most 
carefully and repeatedly examined. 

Prognosis. The prognosis of simple fibrinous pneumonia, occur- 
ring in a young and healthy subject, under favorable conditions uncom- 
plicated by alcoholism, is very favorable ; but old people, children, 
drunkards, and the victims of other infective diseases yield a very 
unfavorable prognosis. Location of the disease in the upper lobes of 
the lungs ; the occurrence of delirium tremens ; a temperature exceed- 
ing 104° F. ; extensive inflammation, especially if it involve both 
lungs ; pregnancy, and the coexistence of other pulmonary or cardiac 
diseases, add greatly to the dangers of pneumonia. The mortality 
varies considerably, according to locality and occasion ; but averages 
not far from 20 per cent. 

Treatment. Like other uncomplicated diseases which pursue a 
definite course, simple fibrinous pneumonia occurring under favorable 
conditions requires very little active treatment. The patient should be 
placed in a well-ventilated apartment in which the air is kept moist 
with a spray of warm water, at a temperature of 72° F. The diet 
should consist of liquids ; lemonade and cold water may be given 
freely, together with a well-diluted solution of phosphoric acid. 

H- — Acid, phosphoric. 3Jss. 

Aquae Oss. — M. 

S. — A tablespoonful every two hours. 

But old people, children, drunkards, and patients in whom pneu- 
monia has been developed as a secondary disease, must be treated very 
differently. The danger of cardiac failure is such that every effort 
must be made to support the strength of the heart. For this purpose 
the remedies which reduce temperature must be administered, viz., 
antipyrine (sixty to ninety grains dissolved in a little warm water, and 
injected into the rectum) ; acetanilide (five grains every two hours), or 
phenacetine (ten to fifteen grains every two hours). Antipyrine thus 
used does not produce the nausea and vomiting which sometimes follow 
its administration by the mouth. Alcoholic stimulants must also be 
administered freely ; they may be given in the form of strong wine, or 
whiskey diluted with water ; an ounce of sherry, or half an ounce of 
whiskey, or even a larger quantity, may be administered every hour in 
asthenic cases. It is well to change the alcoholic stimulant from time 
to time, so as to avoid the disgust which sometimes arises if the patient 
is confined to one variety of wine or liquor alone. Quinine, salicylic 
acid, benzoate of sodium, tartar emetic, veratrum viride, digitalis, and 
venesection are remedies to be avoided rather than employed in pneu- 
monia. If alcoholic and antifebrile remedies fail to obviate the ten : . 
dency to collapse, it will be necessary to administer camphor, capsicum, 
or musk, which may be given in grain doses every hour. A tendency to 
cyanosis may frequently be arrested by the administration of strychnine : 

H- — Strych. sulph. ........ gr. j. 

Quin. sulph. ........ gr. viij. 

Acid, sulph. afomat. . . . . . 3ss. 

Aqiue camphor. ....... ^xvs*. — M. 

S —A teaspoonful in water every two hours. 

31 



482 DISEASES OF THE ORGANS OF RESPIRATION. 

The occurrence of bronchial catarrh may render necessary the use of 
expectorant mixtures. 

R. — Apomorphin. gr. j. 

Acid, hydrocyan. dilut. ... 1T|.xv. 

Glyeerinae . . . . . . . 25 ss. 

Aqua? camphor. ....... ^jss. — M. 

S. —A teaspoonful every two to four hours. 

R.— Syr. ipecac, \ ~ 

Tr. opii camphorat. I " ^ " " 

Glycerin %]. — M. 

S. — A teaspoonful every two to four hours. 

Pain in the side may be relieved by the application of dry or wet cups, 
or a half-dozen leeches, and by large poultices surrounding the affected 
side of the thorax. In the treatment of young children an oiled-silk 
jacket, lined with soft flannel, is frequently a sufficient substitute for 
poultices. Insomnia may be relieved by the use of chloral hydrate in 
thirty-grain doses, at bedtime, or by the administration of paraldehyde 
in drachm doses, or of sulphonal in half-drachm doses. In all cases of 
pneumonia, narcotics should be employed with the greatest caution, by 
reason of the great tendency to cardiac paralysis and collapse which 
characterize the disease. Only in cases of uncomplicated pneumonia 
occurring under favorable circumstances, in young and healthy persons 
with a vigorous heart and no apparent tendency to cyanosis, should 
opiates be administered. 

During convalescence the ordinary therapeutic measures may be 
employed, including good diet and careful avoidance of exposure, on 
account of the strong tendency to collapse that often exists : iron, 
quinine, and strychnine will be found useful in small doses. 

Interstitial Pneumonia — Pneumonia Interstitialis. 

Acute interstitial inflammation of the lungs involves the interlobular 
connective tissue, and cannot be distinguished during life from abscess 
of the lungs. Chronic interstitial inflammation of the lungs is gen- 
erally a secondary disease, occurring in connection with chronic bron- 
chitis, pleurisy, and any form of disease involving the lungs. A senile 
proliferation of the pulmonary connective tissue has sometimes been 
described, but the disease is usually of a secondary character. 

Pathological Anatomy. Chronic interstitial pneumonia may exist 
in the form of circumscribed indurations of a light-gray or pink color, 
or of a very dark and slaty hue. The diffuse form of the disease is 
manifested by the existence of white, gray, or slate-colored stride which 
envelop the pulmonary lobules of the lungs, and compress the air cells. 
As the disease progresses, the inflamed tissues contract, and, conse- 
quently, the pleural surface of the lungs becomes uneven, like the 
corresponding surface of the liver or of the kidneys when those organs 
have undergone inflammation and contraction of their connective tissue 
(cirrhosis). 

Since chronic interstitial pneumonia is usually a secondary conse- 
quence of other pulmonary diseases, the pathological changes which 



DISEASES OF THE LUNGS. 



483 



characterize the primary disease will also be present, e. g., abscess, 
gangrene, caseous deposits, tubercular cavities, bronchitis, etc. 

Symptoms and Diagnosis. Chronic interstitial pneumonia can 
only be recognized during life when it has progressed to the extent of 
producing considerable contraction of the affected portion of the lung. 
Circumscribed forms of the disease may be surrounded by a zone of 
vicarious emphysema, by which the effects of contraction may be com- 
pletely masked. When existing in the circumscribed form, it is most 
easily recognized at the apex of the lung ; the space below the clavicle 
then appears sunken, and is dull on percussion. If the whole lung be 
involved, the entire half of the thorax appears contracted and dimin- 
ished in size (Fig. 104). The corresponding shoulder droops, and the 
lower portion of the shoulder-blade projects away from the thoracic 
wall. The movements of respiration are much restricted upon the 

Fig. 104. 




Unilateral retraction of the chest; consequent upon cirrhosis of the left lung in a girl 
of fourteen years. The figures indicate antero-postero and transverse diameters, and 
semicircles of right and left chest. (Dr. Gee.) 



affected side. As a consequence of contraction of the left lung the 
heart may be unusually exposed, so that its pulsations become extra- 
ordinarily visible. Sometimes the organ is drawn upward by the re- 
tractile process, so that the apex pulsates in the fourth intercostal space ; 
and it may be in the same way drawn outward as far as the axillary 
line. In such cases the systolic dilatation of the pulmonary artery may 
be perceived in the second left intercostal space. 

Palpation indicates reduction in the width of the intercostal spaces, 
diminution of the respiratory movements, together with increased vocal 
fremitus if the vesicular structures are extensively destroyed by com- 
pression. If, however, the bronchi have been themselves obliterated 
by the contractile process, vocal fremitus will be correspondingly 
diminished. 

Percussion indicates dulness and diminution in the volume and 
mobility of the lungs. In cases complicated by the formation of pul- 



4^4: I'ISZASEi J] THE ORGANS OF RESPIRATION. 

monary cavities, tympanitic and metallic Bounds will be heard on per- 
il. As uence of vertical contraction of the lungs, the 
apex may be drawn below its normal level, and the base of the lungs 
ipy a higher plane. Thus the liver may be displaced above 
its natural -: :sition without enlargement of its volume. 

Ausc ~~ t indie tes the absence jf respirat r the 

acted portions of the lungs. Bronchial breathing will be audible 
if the bronchi remain uninjured. The existence of pulmonary cavities 
occasions the occurrence of sonorous rales, with bronchophony and 
bronchial breathing characterised by a metallic resonance (amphoric 
or cavernous respiration!. The cardiac sounds are very distinct, and 
the diastolic sound over the region of the pnbn rtery is accen- 

tuated. 

The occurrence of chronic interstitial pneumonia occasions more or 
less respiratory insufficiency, which is characterized by breathlessness. 
rapid respiration, and. in severe cases, cyanosis. The increaa 
■ i essnre in the pulmonary artery occasions dilatation and hypertrophy 
of the right heart, which is followed, when the cardiac muscle fails, by 
the well-known symptoms of obstructed circulation. 

Prognosis. The prognosis is unfavorable, not only by reason of 
the progressive character of the disease, but also as x>nse nenc 
the dangerous nature of the primary diseases by which chronic inter- 
stitial pneumonia is excited 

Treatment. Chronic interstitial pneumonia is an incurable disc 
The only therapeutic measure that can exert any direct etfect upon its 
: msequences consists in the daily exercise of the affected side, in uni- 
lateral cases, by respiratory gymnastic movements. The body should 
be inclined toward the healthy side, and the lungs should be repeatedly 
inflated, while the arm is raised above the head so as to expand the 
contracted lung to its greatest ssible extent. Such treatment is 

give better results than the alternate respiration of compress 
and rarefied air. 

Pulmonary Abscess — Abscessus Pulmonum. 

Pidm&n e& is a rare disease, more frequent among men than 

among women. 

ETIOLOGY, Suppuration of the pulmonary tissue is excited by the 
genie micrococci, notably staphylococcus pyogenes aureus. It fre- 
quently follows fibrinous pneumonia, especially when the upper lobe 
of the lung has been involved. Catarrhal inflammation, emphysema. 
indurations of the lungs, embolisms of the branches of the pulmonary 
artery, if derived from infective sources, injuries, and foreign bod: - 
the bronchi, may all act as exciting causes of pulmonary abso as 

Pathological Anatomy. The occurrence of npulm 
implies the existence in the lungs of a cavity that is filled with pus. 
Its size may vary from that of a pea to that of an _ It may 

occupy the entire lung. The cavity of the abscess is irregular in form, 
and sometimes consists of a number of communicating spaces. The 
inner surface is uneven, roughly villous, and is covered with a thick 



DISEASES OF THE LUNGS, 



485 



layer of yellowish or gray pus. The periphery of the abscess is sur- 
rounded by a capsule consisting of pulmonary connective tissue which 
has undergone chronic interstitial inflammation. Pulmonary abscesses 
may be single or multiple. They are usually situated in the upper 
lobe of the lung. 

Symptoms. The most important symptom of pulmonary abscess is 
furnished by the expectoration of pus which contains shreds of broken- 
down 'pulmonary tissue. The quantity of the sputa may vary from 
half a pint to a quart each day. It is sometimes thrown up in large 
mouthfuls, after the patient has for some time lain upon the affected 
side so that the cavity has become filled with pus. If any obstruction 
prevent its free discharge, putrefaction may occur within the cavity of 
the abscess, producing an offensive odor which disappears if free vent 
be given to the pus. Permanent obstruction may lead to the develop- 
ment of pulmonary gangrene. 

Microscopical examination of the debris contained in the sputa in- 
dicates the presence of elastic fibres from the connective tissue frame- 
work of the air cells, mixed with degenerated epithelium, fat crystals, 
masses of pigment, hsematoidin, and various microorganisms. (Fig. 
105.) The pus from a chronic pulmonary abscess contains fewer 



Frr;. 105. 




Elastic fibres of lung tissue obtained from sputa after digestion in caustic soda. 
(Drawn by Dr. John Wilson.) 

vesicular elements and a larger amount of fibres derived from the in- 
durated connective tissue which has been the seat of chronic inflamma- 
tion. Cholesterine tablets are also visible in the expectorated matter. 
(Fig. 106.) 

Abscesses of considerable size which lie superficially may be recog- 
nized by the ordinary physical signs of a pulmonary cavity, viz., 
d illness, if the cavity is filled with pus, and a metallic resonance when 
it is distended with air ; elevation of the 'pitch and " cracked-pot 
sound" when the mouth is open; bronchial breathing and sonorous 
rdles. 

Hectic fever and rapid emaciation characterize the progress of the 
disease, which may either terminate in recovery and cicatrization, or 
the inner surface of the abscess may become transformed into a fistulous 






ffi 



486 DISEASES OE THE ORGANS OF RESPIRATION. 

passage, continually discharging pus or muco-pus. Death ruav result 
from exhaustion, or from suffocation through rupture of an al - 

into the air passages, or as a consequence of 
Fig. 1 06. gangrene. Sometimes pus may find its way 

.__ into the pleural cavity, or into the liver, or it 

=A. may excite pericarditis, or it may penetra:e 

=s-\- the thoracic wall and escape externally. 

Diagnosis. Pulmonary abscess may be 

distinguished from abscesses which have found 

their way from other organs into the lungs 

~ by the history of the case, by the evidences 

^ I= ~ ~ of disease in the organs where suppuration 

. — - ' _ originated, and by the absence of pulmonary 

debris. Pus derived from a tubercular cavity 

in the lungs may be recognized by the pres- 

„ ~ ! ence of tubercle bacilli. G f the 

* , __. t-v.^ lungs is indicated by the horribly offensive 

sputa, which contain mycotic plugs in which 

microscopical examination discovers the presence of leptothrix pul- 

monaiis. 

Prognosis. Pulmonary abscess is a very dangerous disease : still 
recovery takes place in a considerable number of cases. 

Treatment. Treatment must be directed with a view to the pi 5- 
ervation of strength, to the arrest of suppuration, and to the preven- 
tion of putrefaction within the abscess. The diet must be nutritious 
and digestible, alcoholic stimulants must be freely given, together with 
iron, quinine, strychnine, and cod-liver oil. Several times a day the 
air of the room should be sprayed with a two per cent, solution of car- 
bolic acid, and the patient may be made to inhale vapors impregnated 
with oil of turpentine, carbolic acid, salicylate of sodium, benzoate of 
sodium, etc. Internally, myrtoi may be given in doses of two or three 
grains, in gelatin capsules, every two hours. This last remedy ap- 
pears to be the most reliable antiseptic for internal use. External 
pointing of the abscess calls for surgical treatment. 

Gangrene of the Lungs — Gangraena Pulmonum. 

Crong 'em if the lungs consists in the death and putrefaction of the 
pulmonary tissue. It is a very rare disease, occurring more frequently 
among men than among women, during the early and middle per; 
adult life. 

Etiology. Pulmonary gangrene occurs usually among the victims 
of poverty and intemperance who have been subjected to over-crowding 
in damp and ill-ventilated quarters. It occurs, sometimes, after severe 
. or during the course of it • ' lei litm Tbe excit- 
ing cause is found in the activity of pyogenic microorganisms, chiefly 
staphylococcus pyogenes aureus et albus. When these organisms are 
comparatively few in number, they produce pulmc ->. but 

their extensive multiplication excites the pulmonary tisi 

which then, if in communication with the external air. becomes in: 



DISEASES OF THE LUNGS. 487 

by the entrance of putrefactive bacteria, and the phemonena of gangrene 
are thus completed. 

Pulmonary gangrene is generally preceded by local disorders, such 
as bronchiectasis with putrid bronchitis, or the entrance of foreign 
bodies into the air passages. Perforation of the air passages, during 
the course of malignant or degenerative diseases in neighboring organs, 
may lead to the introduction of foreign substances into the lungs, with 
subsequent gangrene as a consequence. A similar accident may occur 
during the process of artificial feeding, in cases of insanity and the like. 

Diseases of the pulmonary tissues, viz., inflammation, abscess, tuber- 
culosis, or parasitic growths, may give origin to the gangrenous process. 

Embolic obstruction of the pulmonary vessels with infective masses 
derived from peripheral sources may also originate the gangrenous pro- 
cess ; thus the occurrence of bedsores, diphtheritic diseases of the skin, 
puerperal infection, abscess of the liver, caries of the petrous portion of 
the temporal bone, etc., may furnish infective material. In like man- 
ner wounds and injuries of the lungs may be followed by gangrene. 

Pathological Anatomy. Pulmonary gangrene may exist in the 
form of circumscribed areas of variable size, which are either single or 
multiple ; or it may be diffused without clearly defined limits, through- 
out extensive portions of the pulmonary substance, sometimes involving 
the entire lung. This form of the disease is more frequently observed 
in the upper lobe and in the right lung. 

Circumscribed gangrene is also observed more frequently in the right 
lung than in the left, and in the peripheral portions of the lower lobe, 
rather than in the middle or upper lobe. 

The gangrenous process commences with the formation of a dark 
slough, similar to that which is formed by the action of caustic potash 
upon the external surface of the body. The slough softens, is saturated 
with an ichorous fluid, and is gradually discharged with the expectorated 
matters, leaving an irregular cavity filled with stinking, purulent, ichorous 
and shreddy fluid. Communicating bronchi open abruptly into the 
cavity, and their mucous lining exhibits a condition of acute inflamma- 
tion which, sometimes, reaches the height of putrid bronchitis and 
bronchiectasis. The neighboring bloodvessels are generally obstructed 
and obliterated ; though, sometimes, a rapid process of mortification 
erodes their walls and occasions hemorrhage. 

The gangrenous cavity is surrounded by a zone of interstitial inflam- 
mation by which it is encapsulated. Recovery is effected by contrac- 
tion of this capsule, and by the formation of granulations upon its inner 
surface which finally close up the cavity. Sometimes, however, the 
healing process is incomplete, and there remains a pyogenic membrane 
which continues to discharge pus. Tumefaction of the bronchial glands 
generally accompanies the occurrence of gangrene. 

Symptoms. Small circumscribed gangrenous masses which do not 
communicate with the external air may sometimes remain without 
symptoms. The occurrence of fever, with profuse perspiration and 
great prostration, accompanied by a horrible odor proceeding from 
the lungs, affords presumptive evidence of pulmonary gangrene ; but 
the most characteristic evidence is furnished by the stinking sputa, 



4^5 DISEASES OF THE ORGANS OF RESPIRATION. 

in which may be discovered the debris of the pulmonary tissue. When 
allowed to settle in a glass, the sputa separate into three lave:-. : 
which the upper contains pus corpuscles and mucus : the middle layer 
consists of a gray, serous fluid containing isolated flakes : while the 
lower layer contains a granular sediment and pulmonary debris. 

The debris of the lungs consists of shreddy masses which are formed 
by the disintegrated connective tissue of the vesicular structures. 
Numerous oil globules, fat crystals, and masses of black pigment, lie 
in the network, together with granular particles which may be recog- 
nized as specific microorganisms. 

Besides the above-mentioned bodies there may be observed numerous 
mycotic masses derived from the smaller bronchial passages ; these 
exhale a frightful odor, and consist of crystals of the fatty acids and of 
htematoidin. associated with oil globules, red blood-corpuscles, and 
parasitic organisms. Certain of these resemble the well-known lepto- 
thrix buccalis, but. in consequence of slight differences, have been named 
leptothrix pulmonalis. These organisms are considered the active 
agents by which the pulmonary tissues are disintegrated and brought 
into the state of putrefaction. 

Fever, marked by severe chills and copious perspiration, usually 
occurs in connection with pulmonary gangrene. Its course is irregular, 
and. sometimes, interrupted by intermissions of variable duration. It 
is evidently dependent upon general infection of the blood. The pulse 
is small, weak, and frequent. Mnaeiation and debility are rapidly 
developed. 

Diffuse gangrene gives occasion for the ordinary physical signs of 
pulmonary infiltration, viz.. Julness. bronchial breathing, sonorous rales, 
increase of vocal fremitus and bronchophony. A circumscribed gan- 
grenous cavity gives occasion for the ordinary physical signs of a pul- 
monary cavity, viz.. tympanitic resonance on percussion, elevation of 
pitch, and cracked-pot sound on percussion when the mouth is open, 
sonorous rales, etc. Obviously the character of the signs will differ in 
accordance with the contents of the cavity, which responds with a dull 
sound when filled with liquid, and with a resonant thrill when it is filled 
with air. 

Among the complications of pulmonary $ . Kcemoptysis is a 

frequent occurrence. It may become a source of danger if very pro- 
fuse. Sometimes pleurisy or pyopneumothorax result from the exten- 
sion of the gangrenous process and perforation of the pleura : or as a 
consequence of infection of the pleural surfaces with microorganisms 
which have found admission through the lymph channels. Sometimes, 
in consequence of pleuritic adhesions, the thoracic wall is directly pene- 
trated, and the contents of the gangrenous cavity find exit upon the 
surface of the body. Gasi - rrfestinal disturbances and diarrhoea are, 
sometimes, excited by the infection of the alimentary canal with the 
contents of sputa which have been swallowed. Generally, g 

! and pyaemia may result from universal • through the 

medium of the circulatory fluids. 

Diftuse pulmonary gangrene may run its fatal course within a few 
days. A circumscribed form of the disease may linger for many weeks 



DISEASES OF THE LUNGS. 489 

or months. Recovery is preceded by gradual subsidence of the symp- 
toms, disappearance of fetor, and cessation of discharge. Incomplete 
recovery implies the persistence of a pus-forming cavity in which putre- 
faction may again arise. Fatal cases are frequently preceded by the 
development of a typhoid condition, with delirium, local spasms, a dry, 
brown tongue, and other symptoms of universal prostration. 

Diagnosis. Pulmonary gangrene may be distinguished from putrid 
bronchitis by the absence of pulmonary debris from the sputa of bron- 
chitis. From empycema which is discharged through the lungs it 
may be distinguished by the exclusively purulent character of the dis- 
charge in that disease. The offensive expectoration which is sometimes 
observed in pulmonary consumption may be distinguished by the pres- 
ence of tubercle bacilli. Offensive breath, which is dependent upon 
other causes than gangrene and putrid bronchitis, may be distinguished, 
in the absence of sputa, by the fact that its intensity is aggravated by 
near approach to the mouth of the patient, while the stench of gan- 
grene uniformly pervades the atmosphere of the apartment in which 
the patient lies. 

Prognosis. The prognosis is very unfavorable, though cases of 
circumscribed gangrene not unfrequently recover, especially when youth 
and previous health concur to increase the power of resistance. 

Treatment. The patient must be supported with abundant nourish- 
ment, and with alcoholic stimulants which not only increase the vigor 
of the heart, but serve to disinfect the contents of the stomach if gan- 
grenous sputa have been swallowed. The air of the room should be 
frequently disinfected with carbolic acid spray (two to four per cent.) or 
with the vapor of hot water containing oil of turpentine. The sputa 
should be carefully disinfected with carbolic acid, or permanganate of 
potassium, or chloride of calcium. The patient should be provided 
with a mask for inhalation, by the aid of which he should as often and 
as long as possible inhale the vapor of carbolic acid, which, as rapidly 
as it can be tolerated, should be increased in strength from a five per 
cent, to a fifty per cent, solution, or even stronger. Poor people who 
cannot procure such apparatus may inhale the vapor of turpentine 
mixed with hot water in a narrow-necked jug or flask, or they may use 
a pasteboard cone containing a quantity of cotton saturated with the 
carbolic acid solution. Permanganate of potassium (0.1 to 0.5 of one 
per cent.), boric acid (1 to 4 per cent.), benzoate of sodium (5 to 10 per 
cent.), salicylic acid (0.2 to 1 per cent.), and other disinfectants, may be 
used in the same way. For internal administration, myrtol, in doses of 
two to three grains, in gelatin capsules, every two hours, is most highly 
recommended. Eucalyptol and other disinfectant remedies have also 
been administered, but without much success. Minor indications, such 
as cough, haemoptysis, vomiting, and diarrhoea may require the adminis- 
tration of opiates and astringents. 

Pulmonary Cancer — Carcinoma et Sarcoma Pulmonum. 

Etiology. Cancerous diseases of the lungs occasionally occur as a 
primary affection. Usually, they are secondary results of a pre- 



490 DISEASES OF THE ORGANS OF RESPIRATION. 

existing development in other parts of the body. Sarcoma occurs very 
rarely in comparison with carcinoma. 

Pathological Anatomy. Encephaloid forms of cancer are of 
most frequent occurrence in the lungs, but all the varieties may exist. 
The disease develops as a diffuse infiltration, or as a circumscribed 
tumor. In either case, the whole lobe or the entire lung may be invaded 
by the disease. In some cases the lungs are occupied by numerous, 
minute, cancerous tumors which greatly resemble a disseminated miliary 
tuberculosis. The non-indurated varieties often exhibit a soft, creamy 
consistence, and their interior sometimes undergoes fatty degeneration 
and evacuation through the neighboring bronchi. Calcification, or ossi- 
fication, may sometimes occur. 

The favorite seat of cancerous growth is in the upper lobe of the 
right lung, which is invaded twice as often as the left lung. Sarcoma 
originates in the connective tissue, while carcinoma is of epithelial or 
endothelial origin. Besides the lungs, other intra-thoracic organs may 
become involved in the carcinomatous process. 

Symptoms. The symptoms of pulmonary cancer depend upon the 
extent and locality of the disease. Diminution of respiratory space in 
the lungs is indicated by shortness of breath, cyanosis, and irregular 
respiratory movements. If the heart and large veins be compressed, 
there will be disturbances of the circulation. As the vesicular structure 
of the lungs is replaced by the new growth, the symptoms of pulmonary 
consolidation will be developed. Associated inflammations of the 
bronchi and tissues adjacent to the cancer will originate the symptoms 
of bronchial catarrh or of pulmonary inflammation. If the cardiac 
region be invaded, the heart will be displaced by the tumor. As the 
thoracic cavity becomes filled by the new growth, its walls become 
elevated and fixed; sometimes the tumor may actually project between 
the ribs. The superficial veins frequently become dilated and distended 
from interference with their discharge into the internal vessels, conse- 
quently the subcutaneous connective tissue spaces in the arms, face, 
neck, and thorax become distended with fluid, and the lymph glands in 
the. neck and in the armpit become tumefied. The sputa frequently 
contain blood mixed with mucus, in appearance closely resembling 
currant-jelly. Similar sputa, it is true, may be occasionally observed in 
pulmonary consumption. Occasionally there is developed a grass-green 
color, due to transformation of blood pigment. Frequently cancerous 
elements can be discovered in the expectorated masses. If decomposi- 
tion take place within the lungs, the sputa sometimes emit an offensive 
odor. If pleurisy with effusion be excited by the cancerous disease, the 
contents of the pleural cavity contain characteristic cells which indicate 
the malignant nature of the disease. 

Death sometimes occurs suddenly from copious hemorrhage. Some- 
times it results from asphyxia or from exhaustion. The disease may 
sometimes be mistaken for pleurisy when the pulse upon the affected 
side is weaker than upon the other side, and when through compression 
of the large arteries a systolic murmur is produced. 

Prognosis and Treatment. The prognosis is invariably bad, and 
treatment can accomplish nothing more than the relief of pain and 
suffering. 



DISEASES OF THE PLEURA. 491 



CHAPTER VI. 

DISEASES OF THE PLEURA. 

Pleurisy — Pleuritis. 

Etiology. Pleurisy is an exceedingly common disease. In ancient 
times it was supposed that pleuritic adhesions represented the normal 
condition of the parts, and that freedom of the opposite surfaces was the 
consequence of disease. Age and sex confer no immunity against the 
disease ; it has been observed in foetal life, and old people not unfre- 
quently experience it. More common among men than among women 
during the period of active life, it is obviously so on account of 
the greater degree of exposure which then occurs. 

Pleurisy is almost invariably excited by certain microorganisms 
which find access to the pleural membrane. Among these the pneumo- 
coccus and the pyogenic cocci are the most conspicuous. Tubercle 
bacilli may attack the pleura, and give occasion for the commencement 
of inflammation. 

As predisposing causes which favor the invasion of microorganisms, 
must be enumerated exposure to cold and wet, with the occurrence of 
infective diseases, and of such disorders as interfere with metabolism 
and elimination ; also blows, wounds, inflammation in neighboring 
organs, and other disorders of the pleura itself. 

Pathological Anatomy. Pleurisy may exist either with or with- 
out liquid effusion. The first form (dry pleurisy — pleuritis sicca) is 
characterized by a fibrinous exudation. The second variety (pleurisy 
with effusion, pleuritis humida) is characterized by a liquid effusion 
which may be either serous, purulent, bloody, or ichorous. Interme- 
diate varieties also exist, in which the products of exudation partake of 
two or more forms. 

All varieties of pleurisy commence with dilatation of the bloodvessels, 
which causes a circumscribed, or more or less diffuse, redness that ap- 
pears either in the form of patches, striae, or of universal congestion of 
the serous surface. At certain points hemorrhagic extravasations may 
be visible beneath the endothelial layer. As the inflammation progresses 
the elements of the serous and subserous tissue become swelled and 
loosened by the incipient effusion. The shining, serous surface becomes 
dull and velvety, like a tarnished mirror. The surface becomes still 
more roughened by the formation of a fibrinous, coagulable exudation 
from the capillary vessels. Numerous embryonic round cells are 
entangled in the meshes of the coagulum. In simple, fibrinous pleurisy 
the exudative process proceeds no further, but the opposite pleural sur- 
faces become adherent through opposition of the inflamed membranes. 
Bloodvessels and connective tissue are developed out of the embryonic 
cells which proliferate abundantly in the exudate. In this way the 



492 DISEASES OF THE ORGANS OF RESPIRATION. 

visceral pleura becomes firmly connected with the costal pleura by the 
development of bands and cords like those which may be seen after 
fibrinous inflammation of the pericardium. If, however, the disease 
does not progress to universal adhesion, partial adhesion may become 
established between the lobes of the lungs, or between the basal surfaces 
of the lungs and the upper surface of the diaphragm where the move- 
ments of respiration do not disturb the pleural walls. Recession of the 
disease may occur without adhesion, when the products of exudation 
undergo degeneration, and are removed by absorption. 

Pleurisy with effusion begins with inflammatory changes that are 
identical with those which have been already described : but the exu- 
date contains very little coagulable fibrin, and consists chiefly of a 
serous fluid which contains flakes of fibrin, isolated blood corpuscles, 
endothelial and embryonic cells. Between the lobes and at the base of 
the lungs, a certain amount of fibrinous exudation is generally deposited, 
and circumscribed flocculent masses of fibrinous exudation occasionally 
appear upon the free surfaces. 

Suppurative pleurisy (pyothorax, empyema) is characterized by the 
presence of a greenish-yellow exudation which consists of pus corpuscles 
floating in a more or less abundant serous liquid. A certain amount 
of fibrinous exudation is usually evident. The pus may be thick and 
creamy like that of an ordinary abscess, or it may be largely diluted 
with serum. 

Hemorrhagic pleurisy is characterized by the bloody character of the 
exudation, which may be bright and fresh, or of a dark brown color. 
The blood corpuscles may exist in all stages of degeneration, and the 
color of the exudation varies greatly, from the brilliant color of fresh 
blood, to the dark lake color of thoroughly disintegrated corpuscles. 

Ichorous or putrid pleurisy is characterized by the presence of a 
gray or dirty brown fluid which exhales an offensive oder. It occurs 
as the result of decomposition in the purulent or hemorrhagic exuda- 
tion, and is usually dependent upon pyaemia, septicaemia, pulmonary 
gangrene. or putrid bronchitis. 

Sometimes the exudation of pleurisy exhibits a milky appearance 
due to the presence of oil globules, granular matter, and cholesterine. 
Sometimes also the exudate undergoes colloid degeneration, so that 
the pleural cavity is occupied by a viscid fluid. These peculiar trans- 
formations may be associated with the development of cancerous 
disi ase of tie pleura. 

The quantity of a pleuritic exudation is exceedingly variable, some- 
times amounting to several gallons, in other cases to a half ounce only. 
Its specific gravity varies from 1015 to 1023. A fluid of less density 
is probably a mere dropsical transudate. A specific gravity above 
1018 quite certainly indicates an inflammatory exudation. 

The liquid mass, in a pleuritic effusion, is seldom free to move with- 
out hindrance in the pleural cavity. Sometimes numerous bands of ad- 
hesion transform the space into a sort of sponge with coarse meshes 
through which the fluid finds its way. Sometimes the fluid is 
imprisoned by adhesions, constituting what is known as i ncy&ted 



DISEASES OF THE PLEURA. 



493 



pleurisy. When several cysts exist, they constitute multllocular 
pleurisy. 

Extensive exudation necessarily produces more or less displacement 
of the thoracic and abdominal viscera. The lung may be compressed 
and completely emptied of air, so as to resemble a small spleen flat- 
tened against the spinal column. (Fig. 107.) The heart may be 

Fig. 107. 




Displacement of mediastinum and left lobe of liver from jaleuritic effusion on the left 
side. The shading indicates the extent of dull percussion. (Finlaysox.) 



pushed far over into the right side of the thorax, in cases of eifusion 
into the left pleural cavity, or in the opposite direction if the effusion 
occupy the right side of the chest. Great depression of the diaphragm 
may drag the heart downward, and be accompanied also by depression 
of the liver or of the spleen according to the side upon which the 
effusion exists. It is obvious that the concurrence of tumors or other 
local diseases within the abdominal or thoracic cavities may originate 
manifold variations from the simple types of displacement. 

Symptoms. Pleurisy may exist without any recognizable symptoms, 
when a circumscribed fibrinous effusion is formed without pain or inter- 
ference with the functions of other organs. Secondary pleurisy may 
also be overlooked in consequence of the prominence of the symptoms 
which characterize the primary disease. As a general rule, however, 



494 DISEASES OF THE ORGANS OF RESPIRATION. 

acute pleurisy is ushered in by chills an 1 ~er which continues in 

a more : less : ::~ is form for three or four weeks, and 

then subsides as the local changes within the pleural cavity recede. S 
acute forms of the disease frequently exhibit longer duration with an 
i egnlai course of the fever. Chronic pleurisy may linger for months,or 
even for years. The general symptoms do not always correspond with 
the amount of local change. Extensive exudation is sometimes accom- 
v moderate fever, and i . 

p .7. Dry pleurisy is characterized by the existence of 

pain, and by ~ li which accompany the movements of res- 

piration. The patient generally lies upon the unaffected side, because 
pressure over the region of inflammation causes an increase of pleuritic- 
pain. For this reason the spinal column is laterally flexed with the 
convex:" toward the healthy side, ; : as ::• relax the tension of the 
inflamed surfaces. Sometimes, however, the patient lies upon the 
back, and as the disease progresses he may even lie upon the lis 
side. 

The movements of * ire restricted upon the side that is 

inflamed. If the inflammation be restricted to the upper or I 

::-:::• n of the pleura, the corresponding portion of the thoracic wall 
will be fixed and as immovable as possible. 

Pal I ::<nfirms the evidence afforded by inspect:;:; as bo the 
restriction of movement in the affected portion of the thorax. Pressure 
in the intercostal spaces >vei the seat of inflammation us an 

increase of pain. By careful observation of the indications thus 
afforded as the finger follows the different intercostal si ices around the 
. : wall, the limits within which pain is experienced may be clearly 
defined. It must not be forgotten, however, that the actual inflamma- 
tion mav extend beyond the : u iers of the painful area, which usually 
occupies the lower portion of the i and lateral walls of the 

thorax. 

The existenor :: ~ . -. between the opposite pleural surfac s 
sions a peculiar thrill which may be perceived when the palm of the 
is placed against the thoracic wall i I j tut The 
sensation is somewhat similar to that which is produced by bending 

:e of new sole-leather. Such fremitus, however, may be 
frequently and for a long time absent. Sometimes it can be felt only 
at the end of inspiration, and it is generally intensified by an increase 
of re- motion. Pressure upon the intercostal spa a a rimes 

increases its intensity. Vocal fremitus is not affected by the occurrence 
: by pleurisy, since the amount of exudation is not sufficient to inter- 
fere with the normal propagation of vocal sounds through the respi: 

ssages. Percussion also indicates no change unless there is liquid 
effusion. 

Th- ar very weak and interrupted upon the 

affect a tly; sometimes they are 

ble to the patient himself, and may be heard at a considerable dis- 

from his I sometimes they are soft and insignificant: not 

unfrequently they are interrupted as if the movement of the pleural 

surfaces upon each other were efl y an intermittent slipping 



DISEASES OF THE PLEURA. 495 

instead of a continuous excursion. The sound is usually most audible 
at the end of inspiration ; sometimes it can only be heard during deep 
and rapid respiration ; it can sometimes be heard during both phases of 
the respiratory movement ; it is a rare thing to hear it during expira- 
tion only. Pressure upon the thcracic Avail also increases its intensity. 
The time during which it can be heard is exceedingly variable, since it 
depends so largely upon the amount and character of the exudate. It 
is usually audible over the lower portion of the anterior and lateral 
walls of the thorax. When it is audible over the apex of the lung it 
is generally associated with tubercular deposits in that region. 

Cough is a common accompaniment of pleuritic inflammation. Some- 
times it is trifling and easily overlooked ; in other cases it adds greatly 
to the sufferings of the patient. The occurrence of bronchial catarrh 
is not necessary for its production. It may be excited by the local 
inflammation alone, since irritation of the pleura is competent to pro- 
duce the reflex movements that are connected with cough. 

The disease frequently commences suddenly, with severe chills and a 
fever that is characterized by the usual phenomena. Sometimes a 
certain amount of cyanosis accompanies its course. 

Sometimes dry pleurisy becomes merged in the form that is char- 
acterized by abundant liquid effusion. In such cases the symptoms of 
fibrinous exudation may be succeeded by those of liquid effusion, which, 
after a time, again give place, as the fluid is absorbed, to the signs of 
fibrinous deposit. 

The occurrence of extensive adhesions may interfere greatly with 
the mobility of the lungs, or with the circulation of blood. In this 
way hypertrophy and dilatation of the heart may be produced; the 
lungs may also become emphysematous through interference with their 
proper expansion. 

Pleuritis humida — pleurisy with effusion. A small quantity of 
a liquid effusion may exist within the thorax without the possibility of 
recognition. The amount must reach fourteen or fifteen ounces before 
it can be positively discovered by the aid of percussion. The thickness 
of the liquid column between the lung and the thoracic wall must also 
be not less than an inch. Besides dulness on percussion, the absence 
of vocal fremitus is also necessary to determine the existence of effu- 
sion. 

Inspection shows a change in the position of the patient. Instead 
of lying upon the sound side, as in dry pleurisy, he now generally lies 
upon the diseased side, so as to permit the freest possible motion of the 
unfettered lung. Sometimes, however, patients may be discovered 
lying upon the back, or even upon the healthy side. 

The side of the chest which is occupied by effusion is considerably 
enlarged. It, however, must not be forgotton that the right side of the 
thorax generally measures about an inch in circumference more than 
the left side. The intercostal spaces are increased, and, sometimes, 
become prominent in consequence of pressure exerted by the liquid 
contents of the pleural cavity. The shoulder is elevated, and the 
spinal column exhibits a slight lateral curvature, with its convexity 
toward the side of the effusion. 



496 DISEASES OF THE ORGANS OF RESPIRATION. 

Respiratory movement is considerably restricted, if not wholly 
abolished, upon the diseased side. Respiration is generally acceler- 
ated, and irregular, or interrupted, in consequence of pain on move- 
ment Increased rapidity of respiration is caused partly by the 
reduction of pulmonary capacity for air, and partly by the disturbances 
of circulation which depend upon compression of the lungs and heart. 
Depression of the diaphragm and increase of temperature also tend to 
accelerate the movements of respiration. 

Displacement of the lungs or of the heart by the effusion depends 
obviously upon the amount of the fluid and upon the mobility of neigh- 
boring organs. Previous adhesions may prevent their displacement, 
even though the amount of exudation be very considerable. When the 
left pleural cavity is distended with fluid, the heart is displaced toward 
the right. It is partially rotated upon its longitudinal axis so that the 
riodit ventricle may reach beyond the mammary line. At the same 
time the left half of the diaphragm will be pushed downward, bringing 
the spleen where it can be felt below the left hypochondrium. The 
semilunar space, which ordinarily indicates the location of the fundus 
of the stomach, will also be obliterated by the same downward pressure. 
When the effusion occupies the right pleural cavity, the apex of the 
heart may be displaced beyond the left mammary line. The right 
half of the diaphragm will also be pressed downward, occasioning dis- 
placement of the liver, which in thin persons may be recognized below 
the ribs, and, like the spleen unler similar circumstances, may exhibit 
vertical movements which correspond with the excursions of the 
diaphragm. 

Sometimes pulsation is visible upon the side of the effusion. Gener- 
ally, but not always, this accompanies a purulent exudation. 

On palpation of the thorax, vocal fremitus is found to be diminished 
or completely abolished over the seat of the effusion. It must not be 
forgotten that vocal fremitus is normally more pronounced upon the 
right side than upon the left. Palpation with the ulnar border of the 
hand or with the aid of a small piece of wood like a pencil, is found of 
assistance in locating the boundaries within which fremitus is present 
or absent. Its suppression is due to the fact that the aerial waves, 
which are propagated from the larynx during vocal utterance, are more 
completely conducted through the vesicular structure of the lungs to the 
thoracic wall than they can be conveyed by transmission from the 
bronchi through a fluid medium. The occurrence of pleuritic adhe- 
sions at any point serves as a local medium for the effectual transmis- 
sion of vocal fremitus, which can then be perceived wherever any 
considerable adhesion exists. 

Pressure with the hand upon the thoracic wall indicates an increased 
resistance. Gentle tapping with the hand or the finger upon the chest 
readily furnishes evidence of this condition. 

Sometimes it happens that pressure upon the thoracic surface pro- 
duces pitting, in consequence of oedema in the subcutaneous tissue. 
This may occur with any form of exudation, and is consequent either 
upon inflammation of the costal pleura (inflammatory oedema), or it 
may be the consequence of obstruction of the circulation through pres- 



DISEASES OF THE PLEURA. 497 

sure upon the large vessels. Fluctuation in the intercostal spaces very 
rarely occurs. When the liver or the spleen have been displaced, they 
can frequently be felt through the abdominal wall. Sometimes a 
distinct furrow can be made out between the upper surface of the liver 
and the diaphragm, but this does not always occur. The protrusion of 
the diaphragm itself can sometimes be recognized below the borders of 
the false ribs. 

Percussion indicates dulness over the region of the effusion. The 
greater the amount of the liquid the higher the upper limit of dulness 
along the spinal column ; the degree of dulness diminishes with its 
ascent, because the amount of liquid is necessarily greater in the lower 
portion of the chest than where it forms a thin layer between the lung and 
the thoracic wall in the middle or upper part of the pleural cavity. When 
adhesions do not exist, the upper limit of the liquid tends to assume 
the horizontal level ; but, frequently, dulness is discovered at the 
higher level behind, rather than in front of the viscera, in consequence 
of the existence of adhesions, which interfere with the free movement of 
the effusion. Dulness also extends about one inch higher than the 
level of the liquid, by reason of the compression to which the lower 
portion of the lung, in contact with the liquid, is subjected. For the 
same reason, in cases of considerable effusion, the percussion in the first 
and second intercostal spaces gives a deep and tympanitic response. 
When dulness occupies the entire half of the thorax, percussion in 
that locality, especially upon the left side, produces a tympanitic 
sound, of which the pitch is varied by opening or closing the mouth. 
Under such circumstances, the principal bronchus and the trachea behave 
like any other smooth-walled cavities which might exist in the lungs, 
and yield on percussion a tympanitic resonance, which varies its pitch 
as the mouth is opened or closed. Sometimes, also, a short and sharp 
blow with the percussion hammer produces the " cracked-pot sound," 
by sudden vibratory expulsion of air through the narrow glottis. 

Auscultation indicates more or less diminution or complete absence 
of vesicular respiratory sounds, in consequence of the fact that the 
liquid effusion forms an inferior conductor for the aerial vibrations that 
are generated within the lungs during the act of respiration. For the 
same reason the sound of bronchial breathing appears exaggerated ; 
though when the exudation is very abundant, it may be diminished, in 
consequence of the remoteness of the displaced bronchi, or by reason 
of their actual compression. Bronchial rales will not be audible, unless 
there be a complicating bronchitis. 

Auscultation indicates an apparent diminution of the vocal sounds, 
excepting where adhesions between the pleural surfaces may exist. A 
limited amount of exudation, however, may increase the vocal sounds, 
in consequence of the augmented conductive power of the compressed 
lung. The same thing may sometimes be observed above the level of 
the effusion. 

It frequently happens that auscultation detects a tremulous and 
nasal quality in the vocal sounds ; this is termed cegophoni/, from its 
resemblance to the bleating of the goat. It generally occurs in con- 
nection with moderate effusions, and is audible along the upper limit 

32 



diseases :r :hi i-egaxs :j respiration. 

of the exudation. It is produced through the agency of the peripheral 
bronchial tubes which have been compressed in such a way that they 
produce a rapidly intermittent trans d of vocal vibrations to the 

thoracic wall. Ex Hnre isly s the lung too far 

away to permit such transmission. 

Tie vibrations which are produced by whu re audible dm 

auscultation over the seat of exudation, just as they may be heard 
pulmonary cavities >i infiltrations of the longs. 

Friction sounds are not uncommon in association with liquid effu- 
sion. They may become audible at the commencement of a pleurisv. 

::t the eriod of effusion; and also at the close of the same, as the 
liquid subsides. At times they may be heard at the upper limit of the 
7 fusion where the pleural surfaces are in contact. 

is - : memoes lej endent >n bronchial catarrh, and some:: 
upon inflammatory inflammation of the pleura itself. The intensity and 
frequency of the cough is subject to great variat::: -. 

" imit of great variety and num- 

since every parr of the body is liable to be disturbed by the local 
disorder. High leva occasions heat and re<iness of the skin: pro- 
tracted purulent exudations may pr: lace pallor and other eviden; 
cachexia, with a degree of emaciation suggestive of pulmonary 
sumption, especially when associated with hectic fever and copious night - 
sweats, loss ::' ippetite, ind <:rength. Pleuritic fever follows no uni- 
form course: sometimes it maybe entirely absent :'or a considerable 
perk i of time. Purulent exudation generally excites an irregular and 
hectic form of fever. Recovery is sometimes ushered in by a sudden 
subsidence of fever : but more frequently it re:r ee gn iually. 

Vomiting sometimes occurs, apparently by reason of mechanical 
pressure upon the stomach. The liver is often enlarged through com- 
pression of the ascending vena cava. The urine is riuced in quantity, 
and sometimes contains albumin and casts 

is a form of the - hich is rest 

to the pleural surface of the diaphragm. It is ushered in with severe 
pain under the hypochondrium. which may extend into the back, 
high as the shoulder, rendering it difficult to lie in certain pniis:: 
The act of swallowing is sometimes attended with pain as the alimen- 
tary Ana] sses through the oesophageal foramen in the diaphragm. 
Vomiting and hiccough are not uncommon when the left side is in- 
volved : while icterus may my inflammation of the right - 

-ure along the costal borders of the diaphragm, and over the phrenic 
nerve in the neck, is painful. Diaphragmatic respiration is more or 
m] ietely abolished, causing considerable want of breath. Some- 
times friction sounds can be heard along the lower portion of the lung; 
ess >n percuss a not apparent unless the amount of fluid 
exudation be sufficient to encroach upon the lateral region of the pleural 
cavhV 

Pi ru rJitis an - metimes follow left-sided pleurisy, 

through the extension of the inflammatory process. 
seldom occurs, unless, as a consequence of long-continued empyema. 



DISEASES OF THE PLEUKA. 199 

the abdominal organs have undergone amyloid degeneration, or when 
malignant tumors favor the production of oedema. 

High fever is sometimes accompanied by symptoms of cerebral dis- 
turbance ; and among children convulsions may occur. Sudden death 
sometimes follows pleurisy with eifusion as a consequence of some 
unusual and excessive muscular exertion, or as a consequence of sudden 
anaemia of the brain, induced by incautious assumption of the erect 
position. Sometimes death is occasioned by embolic processes which 
result from the formation of cardiac thrombi dependent upon a feeble 
circulation of the blood. Long-continued exudation may result in 
cardiac degeneration, with- sudden death as a consequence. 

Empyema sometimes results in evacuation of the purulent effusion 
through the lungs, or into other visceral cavities, or through the ex- 
ternal wall of the thorax. Such external rupture produces what is called 
empyema necessitatis. Its occurrence is attended by phenomena 
which resemble the pointing of an abscess. The cutaneous surface 
becomes cedematous and prominent, and fluctuation may be detected. 
The swelling appears smaller during inspiration, but it is increased by 
movements of expiration, and by coughing or straining. Sometimes 
the tumor pulsates in a manner similar to what may be observed in 
aneurismal tumors. Gradually the surface of the skin becomes red- 
dened and thinner, until, at last, rupture takes place, and pus streams 
forth. The discharge may resemble the contents of an ordinary abscess 
(laudable pus) or it may exhale a sour, or even an offensive smell if air 
finds access to the pleural cavity. The point of rupture is usually 
between the ribs near the sternal border, or in the fifth or sixth inter- 
costal spaces between the mammary and axillary lines. Occasionally, 
a fistulous passage is formed, through which the pus escapes at a long 
distance below the thorax. 

Sometimes the discharge of pus gradually diminishes, and the healing 
process may be accomplished. Frequently, however, a reaccumulation 
occurs, and the patient finally dies, exhausted by hectic fever and pro- 
tracted suppuration. Amyloid degeneration may also invade particular 
organs of the body, producing death from dropsy or diarrhoea. Carious 
diseases of the bones may also complicate the disease. 

Empyema may evacuate itself through the lungs by a gradual dis- 
charge, or by an overwhelming rush of liquid into the bronchi and 
trachea, sometimes producing suffocation and death. At first, the 
expectoration may consist of laudable, or of sour-smelling pus ; but, 
after a time, it frequently acquires the odor of putrefaction, in conse- 
quence of the admission of air into the pleural cavity. If the discharge 
take place through a valvular opening in the pleural wall, air may 
still be excluded from the pleural cavity, and decomposition may thus 
be avoided. Obstruction of the discharge usually occasions an increase 
of fever, which continues until renewed evacuation of pus is effected. 

Sometimes pus finds its way from the pleural cavity into the peri- 
cardium, or into the mediastinum, or directly into the larger air passages, 
or into the oesophagus, or the alimentary canal below the diaphragm, or 
into the renal passages. 

The pervasive character of the infection by which pleuritic inflamma- 



500 DISEASES OF THE ORGANS OF RESPIRATION. 

tion is excited is, sometimes, additionally illustrated by the concurrent 
invasion of the kidneys, producing acute nephritis. 

The results and sequelae of pleurisy are exceedingly numerous. A 
serous effusion is sometimes absorbed, and is followed by complete 
recovery of the health ; but, usually, adhesions between the pleural 
surfaces are formed and persist throughout the remainder of life. They 
occasion sharp pain in the sides of the chest, on exertion or in connec- 
tion with deep respiratory movements. Extensive adhesion causes, 
under such circumstances, considerable difficulty in respiration. The 
heart may become involved by the existence of such adhesions, which 
interfere with the freedom of its action : more or less evidence of 
extensive and chronic thickening of the pleura is frequently furnished 
by the persistence of dulness, with reduction of vocal fremitus and 
respiratory sound in the affected portion of the thoracic cavity. Long- 
continued compression of the lungs often produces permanent occlusion 
of the vesicular spaces, so that, after absorption or removal of the liquid 
effusion, the lungs remain permanently contracted. The thoracic wall, 
consequently, becomes permanently retracted, partly through the 
uncompensated pressure of the atmosphere upon the external surface 
of the thorax, and. partly, as a consequence of direct traction through 
contraction of the products of exudation. Upon the diseased side the 
ribs overlap each other : the spinal column exhibits lateral curvature, 
with its convexity toward the healthy side ; the shoulder droops upon 
the affected side : and the movements of respiration are, for the most 
part, restricted to the healthy portion of the thorax. The physical 
signs are those which indicate compression of. or absence of air from, 
the pulmonary tissue. The heart and liver, if not bound down by 
previous adhesions, undergo dislocation in correspondence with the 
locality and the amount of retraction. 

One of the most serious consequences of pleurisy is the frequent 
development of pulmonary tuberculosis, either in connection with the 
disease or as a consequence of its previous occurrence. This mis- 
fortune is more likely to follow serous effusion, especially in cases that 
are marked by a predisposition to tuberculosis, than after well-managed 
purulent exudation. A neglected empyema may. nevertheless, lead to 
caseation, or calcification, and bacillary infection of the products of 
inflammation, with general tuberculosis as the final result. 

DIAGNOSIS. Dry pleurisy may be easily recognized when friction 
sounds are audible, but they must be carefully distinguished from other 
sounds which have their origin within the thorax, viz.. bronchial rales 
and pericardial friction sounds. From bronchial rale* the friction 
sound of pleurisy may be distinguished by the fact that pressure with 
the stethoscope increases a friction sound, while bronchial rales are not 
thus affected. The act of coughing, by which the air passages are 
temporarily emptied of their contents, causes a cessation <:»f rales, but 
has no influence upon friction sound. Bronchial rales are also more 
generally diffused than friction sounds, which are frequently quite cir- 
cumscribed. 

The occurrence of dry pleurisy in the vicinity of the pericardium 
occasions a certain amount of confusion, since the Bounds are modified 



DISEASES OF THE PLEURA. 501 

to a certain extent by the movements of the heart ; but these pleuro- 
pericardial sounds may be distinguished by the fact that their re- 
spiratory constituent is greatly influenced by variations in the depth of 
the respiratory movements. Holding the breath also causes a speedy 
disappearance of the pseudo-pericardial constituent of the friction sound, 
which reappears as soon as respiration is renewed, while a similar arrest 
of respiration after a deep inspiration causes a considerable increase in 
the intensity of genuine pericardial friction sounds. Pleuro-pericardial 
friction sounds are, also, most distinctly audible near the left border of 
the apex of the heart, while genuine pericardial friction is more audible 
over the middle third of the sternum, and in the third and fourth inter- 
costal spaces along the border of the breast-bone. 

In the absence of pleuritic friction sounds a painful pleurisy must 
be distinguished from intercostal neuralgia, from muscular rheumatism, 
from inflammation of the ribs, and from cutaneous diseases. The last 
may be excluded by inspection of the thoracic surface. Intercostal 
neuralgia is characterized by transient paroxysms of pain which usually 
affect only one intercostal space from the spinal column to the sternum. 
The existence of painful points which correspond to the location of the 
dorsal, the lateral, and the sternal branches of the intercostal nerve, 
furnishes important evidence of neuralgia. Caries of the ribs may be 
distinguished by the greater intensity of pain when the ribs undergo 
pressure, while in pleurisy the tenderness is greatest when the inter- 
costal spaces are pressed. Muscular rheumatism is sometimes difficult 
to distinguish when it affects an extensive territory, and is accompanied 
by painful respiration and its consequences. When the larger pectoral 
and dorsal muscles are involved, their painful condition is increased by 
pressure between the fingers. 

Pleurisy ivith effusion must be distinguished from infiltration of the 
lungs by the character of the vocal fremitus, which is diminished in 
pleurisy but is increased in pneumonia. The concurrence of a pleuritic 
effusion with pneumonia will cause the abolition of vocal fremitus over 
the seat of effusion. In like manner, it will temporarily disappear 
when the upper bronchus of a pneumonic lung is obstructed by secre- 
tions which exclude the tracheal vibration from the pulmonary territory. 
The distinction between pleurisy and pneumonia may be facilitated, in 
certain cases, by the character and locality of dulness on percussion, 
since dulness in pleurisy increases as the lower portion of the thoracic 
cavity is approached. Dulness in its superior portion, while the lower 
part remains resonant, would be decisive in favor of pneumonia or 
other infiltration of the upper lobe of the lung. Left-sided pleurisy 
also obliterates the semilunar space where the stomach bulges upward, 
while pneumonia produces no limitation of that space. Bronchial 
respiration is less audible in pleuritic effusion than in pulmonary infil- 
tration. The presence of rusty sputa and the rapid and cyclical course 
of the symptomatic fever are indicative of pneumonia. Displacement 
of the heart and other thoracic organs indicates pleurisy rather than 
pneumonia. 

The occurrence of tumors involving the lungs or the pleura occa- 



diseases :■ ? in: organs >f rbspib atiov. 

si ds _ : lifficnlty gnosis. Sometimes an eaq puncture 

of the thorax greatly aids in differ^ _ a - 

A sy in the i le _1 : orhood of the pericardium 

may lead to a suspicion of pericarditis, bur its outline is generally i 
irregular than that of the pericardial enlargement : while the displace- 
ment :: the .-ardiae apex and the presence :: pericardial friction sounds 
and changes in the locomotion of the heart suffice :: identify a pericar- 
rffusion. 

A circumscribed pleuris cgion may be mistaken for 

a tumor ;:" the spleen. An enlarged spleen exhibits alternate lis- 
-ments which eorresj ra with the movements ::' respiration, while 
a circums pleurisy presents nothing of the kin 

A mc lei ite accumulation of liquid in the right thoracic cavity may 
be [istingnished from enlargement of the " i • y the fact that eni ge- 
no snt :: :hat organ generally causes | i : trnsi n ; : its I : wer border below 
the ribs. T\~Len that border occupies its normal position an increase 
of dulness in the lower portion of the chest must be iscribed to pleu- 
risy. If the upper limit of dulness be higher in front than behind, it 
is probably caused by a tumor or abscess in the liver. Hepatic en- 

rgements ::' every kind exhibit movements in conformity with the 
respiratory excursions of the diaphragm, while pleuritic exudations 
not Thus affected. The intercostal spa aea ire tended by effusion, but 
remain uninfluenced by hepatic tumors, which often cause pro- 

jection of the lower ribs. Hep::: lisease is. Is ,fire aentlyass 
with symptoms of icterus and other evidences of biliary die 
Finally, the existence :: sub-diaphragmatic abscess in the form of an 
accumulation of pus between the diaphragm and the liver, or the spleen, 
may sometimes lea id :: confusion with empyema. The hist >i j : 

ses usually points to the previous iccurrence of abscess or echin--»- 

:n the liver, :: to suppurative peritoni: is on of 

the gall-bladder, or stomach, or intestines, or to suppuration of the 

:r to a para-nephritic inflammation outside of the peritoneal 

ity. 

It is we"/. :;• remember in cases where the question arises as to the 
tnce of fluid in the pleural cavity, or as to the character of such 
fluid, that an a, under antiseptic pre s, will. 

withoul _ r. give the desu information. 

E ; ; - - | ; d be distinguished from an abscess 

with caries of the a by the presence of the physical signs 

Lenrisy and by the - a of sym: tome . heating spinal d> - 

I by the aceumulat 
of the costal pleura itself, is distinguished from empyema by the fact 
that the intercostal sp a iilated only over the region occupied by 

the a acess F q iration and cough do not cause its uni - 

enlargement : nor olume be reduced by pressure from without. 

. evacuation of its contents the finger readily reaches the ba- 
the a ss, which it cannot do when an empyema is ope: 

The leak s for a differential d _- 

Dosis befc sen that dis 3 md thora i. The following 

rules have been I d for the establishment of the distin 



DISEASES OF THE PLEURA. 503 

1. Aneurismal tumors generally appear upon the upper and anterior 
portion of the right thoracic wall ; while pulsating empyema generally 
occupies the lower portion of the left side of the chest. 2. An em- 
pyema may be modified by pressure and by respiratory movements ; 
but an aneurism cannot be thus changed. 3. Aneurismal dulness on 
percussion is restricted to the limits of the tumor ; but in empyema 
dulness is generally diffused over the thorax. 4. Aneurismal mur- 
murs are generally audible ; while the region of an empyema remains 
silent. 

In order to ascertain with positive certainty the character of the 
effusion in pleurisy, it is necessary to perform exploratory puncture of 
the pleural cavity. This may be easily performed with a large hypo- 
dermic syringe which has been thoroughly cleansed and disinfected. 
The operation should be performed by plunging the canula through the 
thoracic wall, in one of the posterior intercostal spaces where dulness 
and other signs have indicated the presence of a liquid effusion. With 
the thumb and forefinger of the left hand placed upon two adjacent 
ribs, the point of the hollow needle should be forced quickly through 
the tissues between the fingers, taking care to avoid the ribs ; a syringe- 
ful of the pleural contents may be then sucked out. If no fluid fol- 
lows the introduction of the needle the barrel of the syringe should 
be unscrewed, and an effort be made with a fine probe to clear the 
canula. It may be necessary to withdraw the needle and to renew the 
attempt at another point. The trifling wound that is made should be 
closed with adhesive plaster. In this way it becomes possible to arrive 
at a decision regarding the nature of the thoracic contents. 

Prognosis. — The prospect of recovery in pleurisy depends upon the 
cause of the disease and upon the character of the effusion. Those 
cases which are dependent upon malignant tumors, and upon chronic 
and malignant diseases, are characterized by a very unfavorable prog- 
nosis ; while dry pleurisy, unless it recur frequently at the apex of the 
lungs, as a consequence of tuberculosis, is generally followed by re- 
covery. 

The prognosis in pleurisy will, then, depend largely upon the amount 
and character of the exudation. Serous pleurisy affords a favorable 
prognosis, except in those cases which are dependent upon tuberculosis. 
Empyema seldom recovers spontaneously ; but the prognosis is com- 
paratively favorable when the character of the effusion has been recog- 
nized at an early period, and when appropriate treatment has been 
employed. Ichorous and hemorrhagic effusions are dependent upon 
causes which render the prognosis very doubtful. The same thing is 
true of effusions that contain tubercle-bacilli. 

The occurrence of excessive effusion adds greatly to the danger of 
the patient through the embarrassment and displacement of the intra- 
thoracic viscera, which may thus occasion great dyspnoea, and which 
also tends to perpetuate itself by compression of the lymph channels 
through which absorption should be effected. As a general rule, the 
longer a pleuritic effusion persists the greater the danger to which it 
exposes the patient. High fever and recurrent exacerbations add to the 
risk. Though pleurisy occurs more frequently upon the left side of the 



504 DISEASES OF THE ORGANS OF RESPIRATION. 

thorax than upon the right side, it is a well-kuown fact that right-sided 
pleurisy is more dangerous, on account of its frequent association with 
pulmonary tuberculosis. 

Treatment. — Dry pleurisy requires treatment in bed, because, if 
the patient be allowed to remain on his feet, there is danger of a liquid 
effusion in addition to the original fibrinous exudation. Warm poultices 
should be applied to the affected side. Hypodermic injections of mor- 
phine and atropine may be given for the relief of pain and cough. If 
these measures do not sufficiently relieve, cups, either wet or dry, may 
be applied with advantage to the thoracic wall. In rheumatic cases, 
chloroform liniment will be found useful. Any considerable degree of 
fever requires the use of phenacetine or acetanilide. 

Uncomplicated serous pleurisy may be treated in the same way; but 
if at the expiration of a fortnight no signs of absorption appear, it will 
be necessary to attempt the stimulation of that process. The bowels 
must be opened daily with gentle laxatives. 

&. — Pulv. glycyrrhiz. comp., ^j— iv. 

Daily. 
R . — Pil- rliei comp., no. i-iii, every night. 

The amount of the urine must be observed, and the quantity of 
liquids consumed by the patient should not be allowed to exceed the 
urinary discharge, otherwise it will be difficult to reduce the effusion. 
It has been customary to adminster mercurials for the purpose of hasten- 
ing the process of absorption, but, with the exception of a three-grain 
blue pill, once or twice a week, it is unnecessary to resort to such 
measures. Iodide of potassium may be given in doses of five to ten 
grains three times a day. Digitalis, in the form of infusion, with 
citrate of potassium, or nitrate of potassium, or acetate of potassium, 
may be given every two hours, daily. Bitartrate of potassium is also 
a useful remedy, especially if the bow r els are inclined to constipation. 
Vegetable diuretics, such as squills, infusion- of fresh parsley root, etc., 
may also be used in connection with saline diuretics and digitalis. 

Vigorous patients may be treated advantageously by the use of cath- 
artic remedies, since active purging such as occurs during a choleraic 
attack, has been known to rid one completely of a long-standing serous 
effusion. The best cathartics for this purpose are the compound infusion 
of senna, compound colocynth pills, compound jalap powder, and pills 
containing croton oil in drop doses. 

The employment of diaphoresis through the agency of hot air or hot 
water baths is attended with considerable danger from dyspnoea. The 
employment of pilocarpine by daily hypodermic injection affords excel- 
lent results, though it is generally expedient to administer wine or 
whiskey, in order to prevent the depressing and nauseating influence of 
the drug. In like manner, salicylic acid or salicylate of sodium, in 
ten-grain doses every half-hour until a drachm has been taken every day, 
often produces excellent results ; though, in consequence of the danger 
of cardiac depression, it is never safe to leave the administration of such 
remedies in the hands of inexperienced persons. In all cases a nutri- 



DISEASES OF THE PLEURA. 505 

tious and abundant diet should be furnished. Weakly and anaemic 
persons should also receive tonic medication. 

R .—Elix. calisay ^ ss. 

Every four hours. 
R. — Elix. gentian, et ferri 3J. 

Every four hours. 

Koumyss, butter-milk, and boiled milk may be given as freely as de- 
sired. 

But, if at the end of four weeks the effusion gives no sign of reduc- 
tion, or at an earlier period if its amount be sufficient to embarrass the 
heart or the lungs, it will be necessary to resort to aspiration of the 
pleural cavity. This may be easily accomplished by the aid of Potain's 
aspirator. The patient should be placed upon the healthy side, with 
the shoulders elevated, in a position intermediate between lateral and 
dorsal recumbency. The apparatus must be thoroughly cleansed and 
disinfected ; having exhausted the air from the flask by the use of the 
air-pump, the trochar-canula should be introduced quickly through the 
thoracic wall in one of the intercostal spaces, as low down as possible 
between the axillary and the scapular lines. Care must be taken to 
avoid the liver or the spleen. The stop-cock between the canula and 
the flask should then be opened, and the fluid will quickly flow through 
the tube that connects the canula with the exhausted receiver. A few 
strokes of the air-pump at intervals will suffice to maintain the partial 
vacuum that is necessary to promote the flow. When a sufficient 
amount has been thus evacuated the canula may be withdrawn, while 
the skin around the tube is pinched up between the thumb and finger, 
in order to prevent the entrance of air into the pleural cavity as the in- 
strument leaves the wound. A piece of adhesive plaster should then 
be applied over the puncture. It is unnecessary to empty the cavity 
of its entire contents, for when the pressure has been largely relieved 
the natural process of absorption generally suffices to accomplish the 
removal of the remaining fluid. Too hasty and too complete evacua- 
tion of the cavity is sometimes followed by oedema of the lungs. The 
occurrence of pain or violent cough, or the transformation of a serous 
effusion into a bloody liquid by hemorrhage, or the intercurrence of 
syncope during the course of the operation, should be accepted as indi- 
cations for its termination. A fatal result sometimes follows syncope, 
when dependent upon cerebral anaemia through excessive evacuation 
of the pleural cavity. Under such circumstances the patient's head 
should be depressed ; alcoholic stimulants should be administered, and 
he may be made to inhale the vapor of ammonia. Sometimes an un- 
favorable result is due to the sudden liberation of a thrombus, produc- 
ing embolism in the lungs, or in the brain, and thus unexpectedly 
terminating life. Death under these circumstances has been known to 
occur in consequence of hemorrhage into a pulmonary cavity which had 
been suddenly relieved from pressure by the withdrawal of the pleuritic 
effusion. 

Under favorable circumstances recovery may speedily follow aspira- 
tion ; but, sometimes, the fluid reaccumulates and requires a repetition 



DISEASES OF THE ORGANS OF RESPIRATION. 

of the operation. If carelessly performed, and. sometimes, even in 
spite of the utmost precaution, a serous liquid may become transformed 
into a purulent accumulation. 

Empyema requires evacuation : :he purulent contents of the pleural 
as Bt mi as i jssible after the discovery of their character: delay 
only increases the exhaustion of the patient, and adds to the danger. 
It is useless ro wait for the tardy and ineffectual operation of internal 
remedies. The aid of the surgeon must be invoked, and the evacua- 
tion of the pleura must be effected by incision and resection of one or 
more ribs. As regards the operation of aspiration, age forms no contra- 
ction. Very young children and old people may be successfully 
ti eated in this way. 

The eration requires complete anaesthesia. The most convenient 

Locality for incision is in the axillary region, between the fifth and 

eighth ribs After removal of the resected portion of the rib. a free 

_ most be made for the evacuation of pus. The pleural cavity 

must be emptied and irrigate with a tepid solution of salicylic acid or 

::_ acid. Carbolic acid and jonosive sublimate solutions mus: aot 

be employed, in consequence of the danger of acute poisoning which 

accompanies such use :: those disinfectants. Proper provision for 

drainage must be made, and at every dressing thorough irrigation and 

drainage must be secure:!. Recovery soon follows, unless tuberculosis 

prevents the healing process: in which case a permanent fistula may 

become established, which will require surgical treatment Sometimes 

tied empyema is discovered which necessitates the opening : 

several cavities. 

Unfavorable symptoms rarely follow the re-described operation; 
but sometimes sync mvnlsions or paralytic symptoms have been 

observed. [These phenomena maybe the result of embolic process - 
suddenly excited by the operation. Similar results have been known 
to follow simple irrigation of the pleural cav after the 

original opera t: 

The existence of a ft. figtui the development of an 

; . r the r; : an empyema through the lungs, all 

~: m " incision and resection of the ribs. 

Hi norr ' > . being dependent upon constitutional dys- 

:>uld not be treatc Is _ . illy unless the danger of death from 

effusion be imminent. Pressure should then be relieved by 

aspiration. 

P t requires the same treatment that is required in 

empyema. Since it is generally connected with the occurrence of pul- 
mon;r _ _.ene. it will be necessary to combine with the operation by 
incision the treatment that is useful in cases of gangrene, 
uritic effne ;urring in connection with pubnai 

precisely like other forms of pleurisy. 
e occurrence of t n after the t d of the 

pleural cavity requires the employment of gymnastic methods for the 

nsion of the contracted lung and development of the retr 
thorax. This must mplished by frequent repetition, many times 

a day, of the act of deep inspiration. y elevation of the 



DISEASES OF THE PLEUEA. 507 

arm and shoulder on the side of the. deformity. This gives better 
results than respiration of compressed air. 

Pneumothorax — Hydro-pneumothorax. 

Pneumothorax signifies an accumulation of air in the pleural cavity ; 
but as this is usually accompanied by the presence of a certain amount 
of fluid effusion, the term hydro-pneumothorax is frequently employed. 
If pus or blood be associated with air, the terms pyo- and hsemo-pneu- 
mothorax are convenient to signify the fact. 

Etiology. Sometimes liquid effusion precedes the entrance of air 
into the pleural cavity. The reverse may be the case. Sometimes 
both air and fluid enter simultaneously, as when a pulmonary cavity 
ruptures and discharges its contents within the pleura. Sometimes 
the entire cavity of the pleura is occupied by air and water ; in certain 
cases they are contained within a space that is circumscribed by adhe- 
sions, constituting circumscribed or encysted hydro-pneumothorax. A 
spontaneous generation of gas within the pleura has been asserted, but 
it is doubtful, though it sometimes happens that no opening can be 
discovered after death through which they could have entered the space. 

Pneumothorax occurs most frequently during the course of pulmonary 
diseases, especially when they are of a tubercular character. Caseous 
deposits immediately beneath the pleural surface may occasion the 
formation of cavities which rupture into the pleural space, and permit 
the entrance of air. This can only occur when rupture precedes the 
formation of adhesions between the costal and visceral pleura in the 
region of an impending perforation. The accident rarely happens at 
the apex of the lungs, but usually along the lower border of the upper 
lobe, or near the upper border of the middle lobe. It is generally 
observed in an antero-lateral portion of the lungs, near the second or 
third intercostal space. 

Besides pulmonary tuberculosis, other ulcerative processes which may 
involve the lungs can occasion the occurrence of perforation and the 
production of pneumothorax. Accordingly it is not uncommon in 
cases of pulmonary abscess or gangrene of the lungs, or as a conse- 
quence of ulceration excited by echinococcus parasites which have 
found their way into the lungs. In like manner, wounds that either 
directly or indirectly occasion perforation of the lungs, may produce 
pneumothorax. Fractures of the ribs may cause laceration of the 
pulmonary pleura and consequent entrance of air into the pleural 
space. 

Excessive muscular exertion, such as accompanies violent cough, 
notably in whooping-cough, and other sudden eiforts, have been known 
to occasion rupture and pneumothorax. Special danger attends such 
exertions on the part of individuals who suffer with emphysema of the 
lungs, by which the superficial air cells have been dilated and atrophied 
almost to the point of spontaneous rupture, an event which, sometimes, 
actually takes place. In like manner peripheral bronchiectasis may 
become the point of communication between the air passages and the 
pleural cavity. 



508 DISEASES OF THE ORGANS OF RESPIRATION. 

Rupture of an empyema into the lungs, or into any other cavity 
that is filled with air, may be the occasion of admission of air into the 
pleura. This event, however, does not necessarily follow a rupture 
through the lungs, because a valvular opening may be formed which 
will effectually prevent the entrance of air. It sometimes happens that 
suppurating bronchial glands open simultaneously into the bronchi 
and into the pleura, producing pyo-pneumothorax. In like manner. 
abscesses and cancerous degenerations of the oesophagus, or rupture of 
that canal, may cause the admission of air. It is often possible 
for ulcerative processes to effect a communication between the stomach 
or intestine and the pleura, with consequent production of pneu- 
mothorax. In the vast majority of cases, however, pneumothorax is 
directly dependent upon pulmonary and pleural diseases. 

Pathological Anatomy. Pneumothorax frequently occasions a 
perceptible distention of the affected side ; and, after death, puncture 
will be followed by the escape, with a hissing sound, of gas, if its ten- 
sion be greater than that of the surrounding atmosphere. The escaping 
stream may be either odorless, or it may liberate an offensive stench 
which is due to the presence of sulphuretted hydrogen. Simple pneu- 
mothorax must necessarily be a very rare event, since the admission of 
air laden with germs which excite inflammation must be followed by 
exudation within the pleural sac. This may be either of a serous, puru- 
lent, hemorrhagic, or ichorus character, according to the nature and 
intensity of the exciting causes. If the gaseous contents of the cavity 
should be subsequently absorbed, the remaining fluid would occasion 
the ordinary symptoms and signs of pleurisy with effusion. 

When the opening through which air has entered the pleura is free 
and unobstructed, the fact is indicated by the term patent pneumothorax. 
When the orifice possesses a valvular character, it occasions valvular 
pneumothorax. In some cases air becomes thus imprisoned and sub- 
jected to a considerable increase of pressure when the valvular opening 
permits access of air only during the act of inspiration. In this way 
the pleural cavity may become greatly distended, and there will be cor- 
responding displacement and compression of the thoracic organs and of 
the diaphragm with the subjacent viscera. (Fig. 108.) Pneumothorax 
by occlusion signifies a condition in which there is no apparent com- 
munication between the air in the pleural cavity and the external 
atmosphere. Transitional forms between these three varieties may 
exist, e.g., a valvular pneumothorax may become transformed into a 
condition of either patency or occlusion. 

The existence of pneumothorax occasions collapse of the lung and its 
compression against the mediastinum or the spinal column. It is some- 
times difficult, if not impossible, to discover the point of perforation in 
consequence of its obliteration by inflammatory exudation. Sometimes 
inflation of the lung under water, will reveal the opening by the escape 
of air-bubbles at the point of rupture. 

Symptoms. The affected side exhibits considerable distention. The 
intercostal spaces disappear, or become actually prominent. Respira- 
tory movements upon the same side are diminished or absent. The 
heart is crowded to the right when the left side of the thorax is filled 



DISEASES OF THE PLEURA. 



509 



with air, and it is displaced to the left when the right side is similarly 
distended. In like manner, the liver or the spleen may be much 
depressed. The patient lies by preference upon the diseased side. 
Many patients are obliged to maintain the sitting posture. Respiration 
is frequently hurried and laborious. A certain amount of cyanosis is 
also perceptible. Vocal fremitus is diminished or entirely suppressed, 
unless preexisting pleuritic adhesions furnish local means of conduc- 
tion to the thoracic wall. At such points the vocal fremitus may be 
perceived even more clearly than under normal conditions. The sense 
of resistance on pressure over the thorax is increased. 



Fig. 108. 




Displacement or mediastinum, heart, and liver from pneumothorax of the right side. 

(Weil.) 

Sometimes when the pleural cavity contains both air and water, a 
sense of fluctuation may be experienced in the intercostal spaces over 
the liquid accumulation. Sometimes on shaking the patient, a distinct 
splashing (succussion sound) can be heard, as if water were shaken in 
a bottle. In certain cases a sound like that of dropping water can be 
heard after such agitation or change of position. It is supposed to be 
caused by drops of liquid trickling down from bands of exudation in 
the upper part of the cavity. 



510 DISEASES OF THE ORGANS OF RESPIRATION. 

The sounds which are evoked by percussion vary according to the 
condition of the thorax. In cases of patent pneumothorax the per- 
cussion sound is very loud and tympanitic, and is accompanied by a 
metallic resonance. In cases of valvular pneumothorax, or of pneumo- 
thorax by occlusion, there is great distention of the chest, and the per- 
cussion sound loses its tympanitic quality and becomes dull. This is 
supposed to be caused by interference between the sound waves that 
originate in the air of the cavity and those that have their origin in the 
vibrations of the thoracic wall. "When the air in the pleural cavity 
communicates freely with the external atmosphere, a short and sharp 
percussion stroke is followed by the " cracked-pot sound/' Changes 
in the pitch of the percussion sound may be observed when the mouth 
is open or closed, for the same reason that produces such changes in 
the pulmonary cavities that communicate with the bronchi. 

Hydro-pneumoihorax gives a great variety of percussion sounds, 
according to the position of the patient, in consequence of the change 
in the level of the fluid which accompanies every change of attitude. 
The pitch of the percussion note also varies according to the posture of 
the patient, because in the erect position the fluid contents accumulate 
in the lower portion of the sac. causing depression of the diaphragm 
and an increase in the vertical diameter of the space that is filled with 
air. A change in pitch must necessarily follow such a modification in 
the form of the resonant cavity. Similar modifications of pitch follow 
every considerable increase or diminution in the amount of fluid exu- 
dation by which the dimensions of the air space are subjected to 
variation. 

Auscultation discovers great variability in the respiratory sounds 
that can be heard. Respiratory sounds are very much weakened, and 
acquire a metallic resonance. Sometimes an amphoric sound can be 
heard. All such sounds are most distinctly audible in the interscapular 
space, where the lungs lie nearest to the thoracic wall. Bronchial 
rales, if present, also acquire a metallic quality, in consequence of the 
fact that all sounds which are transmitted from the respiratory organs 
through the air-filled cavity of the pleura excite, within its space, aerial 
vibrations which are characterized by a metallic resonance. Similar 
metallic qualities accompany the sounds which are heard in connection 
with hvdro-pneumothorax. since they have their origin in the vibra- 
tions which originate in the air-filled space above the level of the fluid. 
Bronchophony also exhibits the same metallic resonance, though 
enfeebled, as it is in pleurisy. 

The sudden occurrence of pneumothorax in cases with previously 
healthy lungs and pleura is attended with very severe symptoms of 
distress. Consciousness may remain unimpaired. There is great com- 
plaint of want of breath, and of severe pain in the lower part of the 
chest, as a consequence of excessive distention of the thoracic cavity. 
The pulse is accelerated : the heart may be considerably displaced, and 
its sounds have acquired a metallic quality in consequence of the 
neighborhood of a resonant cavity in the pleura. The peripheral veins 
give indications of obstruction in the way of the return of blood to the 
heart. After a time the extremities may, consequently, become oedema- 



DISEASES OF THE PLEURA. 511 

tous, while venous hyperemia in the brain occasions sensations of dizzi- 
ness, pressure in the head, ringing in the ears, and other symptoms of 
cerebral engorgement. The liver or the spleen may be crowded down- 
ward by depression of the diaphragm, so that they can be felt below 
the short ribs. The renal secretion is diminished, and sometimes con- 
tains traces of albumin. General subcutaneous emphysema may be 
developed if air finds its way into the connective tissue of the lungs 
and mediastinum. 

Pneumothorax may continue for several weeks or months ; some- 
times death follows within a few minutes from asphyxia. If life is not 
thus quickly terminated, the symptoms of dyspnoea and great prostra- 
tion will remain prominent. In cases of hydro-pneumothorax life has 
been prolonged for many years; but if the effusion should become 
purulent death is very likely to follow amyloid degeneration of the 
vital organs. Recovery sometimes occurs, even after pulmonary gan- 
grene or tuberculosis. Sometimes the air is absorbed from the pleural 
cavity, and the disease persists in the form of pleurisy with effusion. 

Diagnosis. In uncomplicated cases of pneumothorax or hydro- 
pneumothorax the diagnosis is seldom difficult. The nature of the 
effusion may be readily determined by an exploratory puncture. But, 
when the contents of the pleural cavity are circumscribed by adhesions, 
it may be difficult to decide between hydro-pneumothorax and large 
pulmonary cavities, or diaphragmatic hernia, or gaseous distention of 
the stomach, or sub-phrenic abscess into which air has been admitted. 

When a pulmonaj'y cavity exists the intercostal spaces are depressed, 
while in pneumothorax they are distended and prominent. Vocal fre- 
mitus is increased over a pulmonary cavity, while it is diminished in 
pneumothorax. The existence of succussion sounds favors the diagnosis 
of hydro-pneumothorax. 

Diaphragmatic hernia has been known to cause the passage of the 
stomach and a part of the colon into the thoracic cavity, with consequent 
development of the physical signs of pneumothorax. 

Gaseous distention of the stomach may give rise to the physical 
signs of pneumothorax ; but the history of the case and the rapid dis- 
appearance of symptoms after evacuation of the stomach will clear up 
the diagnosis. 

Perforation of the stomach or intestines by ulceration may produce 
sub-phrenic pyo-pneumothorax ; but the previous history of the case, 
and the absence of pulmonary symptoms, will generally remove doubt. 
If a fecal odor follows exploratory puncture, the case belongs to the 
sub-diaphragmatic class. 

Prognosis. The prognosis is always very grave ; especially is this 
true of any sudden and unexpected cases which are liable to run a rapid 
and fatal course. Valvular pneumothorax is the most dangerous form 
of the disease, because of the excessive distention of the pleural cavity, 
and consequent displacement of thoracic viscera, which it occasions. 
The predisposing causes of pneumothorax are often such as to render 
recovery doubtful or impossible. 

Treatment. The symptoms of collapse and asphyxia, which fre- 
quently follow the sudden development of pneumothorax, must be 



512 DISEASES OF THE ORGANS OF RESPIRATION. 

opposed by the administration of alcoholic stimulants, by the hypodermic 
injection of ether, and the use of camphor, valerianate of ammonia, or 
the aromatic spirits of ammonia. Dry cups, mustard plasters, or other 
cutaneous irritants may be applied externally. Dyspnoea which is de- 
pendent upon nervous excitement, in consequence of the sudden advent 
of pneumothorax, may be somewhat relieved by measures which tran- 
quillize the patient. Persistent difficulty of breathing may be relieved 
by the cautious use of small doses of morphine and atropine hypo- 
dermically. Great displacement of the thoracic viscera may be relieved 
by aspiration. This operation is most successful in pneumothorax by 
occlusion, since the valvular form of the disease may readily be repro- 
duced, When the tension of the air within the pleural cavity exceeds 
that of the external atmosphere it will readily escape through an or- 
dinary trocar, the external orifice of which should be covered with 
antiseptic cotton, in order to prevent the admission of air into the tho- 
racic cavity through accidental reversal of the current. The puncture 
should be immediately closed with sticking-plaster as soon as the trocar 
is withdrawn. In cases of pneumothorax by occlusion the ordinary 
aspiration apparatus should be used. If the liquid contents of the 
pleural sac are purulent, the ordinary treatment of empyema by incision 
will be required. Serous effusions need not be removed, unless their 
quantity be sufficient to endanger life. The same rules apply when 
hydro-pneumothorax occurs in connection with pulmonary tuberculosis. 

Hydrothorax. 

Hydrothorax is an accumulation of dropsical fluid in the pleural 
cavity. 

Etiology. Hydrothorax is almost invariably associated with other 
symptoms of general dropsy which depend upon a common cause. This 
usually lies in a diseased condition of the respiratory apparatus or of 
the heart. The existence of tumors, etc., which compress the superior 
venae cavse may lead to thoracic dropsy. Local changes in the walls 
of. the capillary bloodvessels, which occur as a secondary consequence 
of certain diseases, notably scarlet fever ; impoverishment of the blood 
in Bright's disease, dysentery, chronic diarrhoea, or leukaemia : and 
cachectic conditions caused by cancer, malaria, or syphilis, are common 
causes of dropsy. A minor degree of hydrothorax is sometimes ob- 
served as a consequence of lingering death accompanied by symptoms 
of interference with the circulation. It has also been observed in cer- 
tain rare cases of obstruction of the thoracic duct. 

Pathological Anatomy. Hydrothorax is generally observed in 
both pleural cavities ; though, sometimes, as a consequence of lying for 
a long time upon the same side of the body, the dependent cavity con- 
tains a larger amount of liquid than is found in the other. The tran- 
sudate is a clear, limpid, greenish-yellow, or amber-colored fluid, some- 
times containing cholesterine and a few endothelial cells. Its reaction 
is alkaline, and the specific gravity is about 1009 to 1012. A specific 
gravity above 1015 usually indicates an inflammatory exudation. 

The pleural surface frequently appears white and cedematous. The 



DISEASES OF THE PLEURA. 513 

lungs are more or less displaced and compressed ; but they can gener- 
ally be inflated, unless they have been long subjected to pressure, or 
bound down by adhesions. The heart, the diaphragm, the liver, and 
the spleen may also be displaced by the accumulated liquid. 

Symptoms and Diagnosis. The subjective symptoms are occa- 
sioned by compression and displacement of the thoracic viscera, 
occasioning difficulty of respiration, asthmatic paroxysms, cyanosis, and 
enfeeblement of the pulse. 

Inspection frequently indicates distention of the thorax, though the 
evidences of downward pressure are usually less than in cases of pleu- 
risy with effusion. The movements of respiration are diminished. 

Palpation. Vocal fremitus is diminished in those portions of the 
thorax which are occupied by fluid ; and the sense of resistance to 
pressure is considerably increased. 

Percussion indicates dulness, and the level of dulness varies according 
to the position of the patient, unless previous adhesions of the pleural 
surfaces interfere with the free movement of the transudate. Unlike 
the majority of cases of pleurisy with effusion, a dropsical transudation 
usually occupies both sides of the chest, unless one pleural cavity has 
been previously obliterated by inflammation and adhesion. 

iEgophony is sometimes audible along the upper surface of the fluid. 
Auscultation further indicates the absence of respiratory murmurs. 
Bronchial breathing may be audible in the interscapular spaces where 
the compressed lungs are situated. 

In doubtful cases an exploratory puncture may throw light upon the 
case. 

Prognosis. The prognosis depends upon the predisposing cause of 
dropsical transudation. 

Treatment. The treatment of hydrothorax is intimately connected 
with the therapeutical management of the underlying disease. This 
usually requires the exhibition of diuretics, purgatives, and diaphoretics, 
together with tonics and a proper dietetic regimen. If the fluid accu- 
mulate in such a quantity as to interfere with the function of the 
thoracic organs, it will be necessary to aspirate the pleural cavities, as 
in cases of pleurisy with serous effusion. 

Hemothorax and Chylothorax. 

Hemothorax consists in an accumulation of blood within the pleural 
cavity, and it may occur as a consequence of wounds, injuries, or hem- 
orrhage from aneurisms or bleeding vessels within the thorax. Chylo- 
thorax has been observed as a consequence of wounds or ruptures of the 
thoracic duct. Such cases are almost inevitably fatal, yet recovery has 
been known to occur. The milky fluid which occupies the pleural 
cavity must not be confounded with pus or with fatty exudations which 
sometimes occur in cancerous diseases of the pleura. The history of 
the case, and microscopical examination of the fluid, will readily deter- 
mine the diagnosis. 

33 



514 DISEASES OF THE ORGANS OF RESPIRATION 



Cancer of the Pleura — Carcinoma Pleurae. 

Cancerous and sarcomatous diseases in other localities of the body 
may be followed by a secondary affection of the pleura?. All varieties 
of malignant disease may also occur, and may originate affections of 
the pleural membranes. Sometimes the tumors are very numerous and 
exceedingly small, almost like miliary tubercles. In other cases they 
reach an enormous size, and occupy the entire cavity of the pleura to 
the great disadvantage of all the thoracic viscera. Their development 
is frequently accompanied by cancerous pleurisy, with an effusion which 
may be either dropsical or inflammatory, and may exhibit all the varie- 
ties of effusion that are dependent upon pleuritic inflammation. The 
svmptoms are at first exceedingly obscure, and they vary in kind and 
in intensity according to the locality and the extent of the cancerous 
growth. It is often impossible to arrive at anything more certain than 
an inferential diagnosis as to the nature of the disease. The concur- 
rence of malignant disease in other parts of the body, and the course of 
the local changes, often afford the principal data for a conclusion. 



CHAPTER VII. 

DISEASES OF THE MEDIASTINUM. 

Mediastinal Inflammation — Mediastinitis. 

Inflammation of the mediastinal connective tissue is of rare occur- 
rence. It may be either acute or chronic, and may occupy either the 
anterior or the posterior portion of the mediastinal space. The acute 
form frequently results in suppuration, while the chronic variety often 
occasions the development of indurated masses, which may consider- 
ably interfere with the adjacent organs. The acute form of the disease 
may be of traumatic origin, or may be dependent upon rheumatism, 
or it may be the result of an extension of the inflammatory process 
from neighboring territories and organs. Infective diseases and pyaemia 
sometimes occasion the development of mediastinal abscess. The chronic 
form of the disease is frequently dependent upon chronic pulmonary 
disease. 

Symptoms and Diagnosis. Acute mediastinitis is characterized 
by the general symptoms of acute inflammation, by local pain and 
tenderness under the sternum, accompanied by cough and intra-thoracic 
distress. The extension of suppuration will be indicated by increasing 
dulness on percussion, either in front or behind, according to the loca- 
tion of the abscess. Pus may escape externally, or it may find its way 
into any one of the intra-thoracic cavities. 

The indurations which result from chronic mediastinitis may pro- 
duce compression of the large vessels within the thorax, and, by 



DISEASES OF THE MEDIASTINUM. 515 

their adhesion with the walls of the (esophagus and subsequent con- 
traction, they may produce diverticula or pouches connected with that 
passage. 

Prognosis and Treatment. The prognosis is not very favorable. 
Death sometimes occurs suddenly, or as a consequence of chronic inter- 
ference with the thoracic organs. The treatment must be conducted 
on general principles. 

Mediastinal Hemorrhage. 

Hemorrhage into the mediastinal connective tissue is sometimes 
observed in connection with rupture of the large intra-thoracic blood- 
vessels, aneurismal tumors, etc., or as a consequence of wounds or 
other injuries. 

Mediastinal Tumors. 

Pathological Anatomy. Carcinoma, sarcoma, lipoma, fibroma, 
osteoma, dermoid cysts, and other growths may become developed in 
the mediastinal spaces. In many cases such neoplasms originate in the 
mediastinal lymph glands and connective tissue. In other cases they 
arise in the organs that lie within the mediastinum, or in other thoracic 
viscera, which become diseased and extend their malignant proliferation 
into the mediastinal spaces. 

Etiology. The disease is more frequent among men than among 
women, and generally occurs during the period of active adult life. 
Tubercular tumors are generally associated with the manifestation of 
tuberculosis in other parts of the body. Leukaemia and pseudo-leukaemia 
are sometimes accompanied by the development of tumors in the medi- 
astinum, as well as elsewhere. Syphilis exerts very little influence 
upon the development of mediastinal growths, unless the inner surface 
of the sternum is first involved. 

Symptoms. The principal symptoms have their origin in the com- 
pression of neighboring organs, when tumors have reached a sufficient 
size to exert such pressure. By the growth of large tumors in the an- 
terior mediastinal space, the sternum and the costal cartilages may be 
pushed outward, and the characteristic appearances of a tumor then 
become visible. Sometimes pulsation may be distinguished, as a con- 
sequence of impulses derived from the large arterial trunks. Obviously, 
the area of dulness will be enlarged in proportion to the size of the 
growth. Tumors in the posterior mediastinal space may produce per- 
ceptible dulness along the spinal column. Displacements of the heart 
and lungs produce the usual symptoms by which the dislocation of those 
organs is recognized. The trachea, the bronchi, the oesophagus, and 
the pneumogastric nerve may likewise give evidence of compression. 
The innominate veins, the venae cavae, and the azygos veins, may thus 
undergo constriction, or occlusion, with the production of consequent 
oedema in the face, neck, and upper extremities. The superficial veins 
upon the thorax also exhibit signs of distention. 

The respiratory apparatus often experiences great interference from 



516 DISEASES OF THE ORGANS OF RESPIRATION. 

the development of mediastinal tumors. One or more bronchi, or the 
trachea itself, may be compressed to a degree that interferes with res- 
piration and articulation. Paroxysms of dyspnoea, asthmatic symptoms, 
and stridulous breathing are of frequent occurrence. Laryngoscopic 
examination often reveals paretic or paralytic conditions of the laryn- 
geal muscles, caused by pressure upon the recurrent nerve. The voice, 
in such cases, may be rendered hoarse and whispering, or it may be 
completely abolished. For the same reason there is danger of the in- 
trusion of foreign substances into the larynx and trachea during the act 
of swallowing. The movements of the heart and of the oesophagus and 
stomach may be greatly obstructed or perverted by pressure upon the 
pneumogastric nerve ; hence the occurrence of oesophageal spasm, hic- 
cough, and vomiting, which are sometimes observed. Pressure upon 
the sympathetic nerve trunk produces changes in the pupil of the eye, 
so that one pupil may be contracted, while the other is dilated. Pain is 
sometimes observed in the upper extremities, or in the spinal column ; 
it is, usually, paroxysmal and often intense. Cough is, generally, very 
severe, though unaccompanied by any considerable amount of expec- 
toration, unless local suppuration occur, followed by subsequent rupture 
of an abscess into a bronchus or into the trachea, when a copious 
purulent discharge may be witnessed. There is great complaint ol 
sleeplessness ; and, sometimes, the symptoms of cerebral hyperemia are 
evident in the form of dizziness, noises in the ears, flashes of light be- 
fore the eyes, etc. 

The duration of the disease depends upon the nature of the tumor 
and upon the rapidity of its development. Sometimes the disease is 
terminated within a few weeks ; in other cases it persists for several 
years. Death occurs as a consequence of exhaustion, or from com- 
pression of the respiratory or circulatory organs, or from obstruction of 
the oesophagus by which the swallowing of fluid is rendered impossible. 
It may also result from intercurrent diseases. 

Diagnosis. Small tumors which do not exert pressure upon the 
neighboring parts may escape recognition. In some cases the existence 
of the mediastinal tumor is a matter of inference dependent upon 
symptoms in distant organs (e. g., laryngeal paralysis, pupillary differ- 
ences, etc.), after exclusion of the symptoms of aneurism, pericarditis, 
circumscribed pleurisy, and mediastinal abscess. The existence of 
malignant tumors in other parts of the body favors the diagnosis of 
similar growths within the mediastinal cavity. 

Prognosis. The prognosis is exceedingly unfavorable, especially 
when the tumor is of a malignant character. 

Treatment. The treatment must necessarily be entirely symptom- 
atic. Iodide of potassium and mercurial preparations are of very 
little value. Tuberculosis of the glands may be treated with cod-liver 
oil and the syrup of the iodide of iron. Sarcomatous growths, with 
leukemic and pseudo-leuka^mic tumors, are temporarily benefited by 
the administration of arsenic. 



DISEASES OF THE THYMUS GLAND. 517 



CHAPTER VIII. 

DISEASES OF THE THYMUS GLAND. 

Since the functions of the thymus gland are unknown, its diseases 
possess comparatively little clinical importance. Hypertrophy of the 
thymus gland may theoretically interfere with the processes of respira- 
tion and circulation ; but obviously such hypertrophy cannot be distin- 
guished from other enlargements in the mediastinal space. Hemorrhage 
may occur into the substance of the gland in hemorrhagic diseases. 
Abscesses and tumors may also become developed in the gland, under 
which circumstances the symptoms of mediastinal abscess or of medi- 
astinal tumor will be observed. 



PART VI. 

DISEASES OF THE ORGANS OF 
CIRCULATION. 



DISEASES OF THE CIRCULATORY APPARATUS. 
CHAPTER I. 

ENDOCARDIAL DISEASES. 

Ulcerative Endocarditis — Endocarditis Ulcerosa. 

Etiology. Ulcerative endocarditis is an inflammation of the endo- 
cardium, usually manifested upon the valves of the left side of the heart 
along the line of contact of their segments when closed by the action of 
the organ. The disease has its origin in the activity of certain micro- 
organisms which find their way through the blood into the cavities of 
the heart during the course of various infective diseases. The entrance 
of these pathogenic organisms may be generally traced to an external 
wound or to a remote septic process, such as may be discovered in the 
uterine organs during puerperal fever. It may also become developed 
as a complication in the course of many infective diseases, such as 
scarlet fever, diphtheria, typhoid fever, pneumonia, empyema, rheuma- 
tism, and suppurative inflammations involving the genito-urinary 
organs. It has been observed that the disease occurs more frequently 
in connection with epidemics of infective disease than when they are not 
prevalent in the community. 

There are, however, cases in which it is impossible to trace a connec- 
tion between the endocardial disease and any prevailing source of infec- 
tion. Of these cases, some no doubt originate in local processes that 
have escaped observation, such as may exist in the nasal passages. 
Other cases, however, may be caused by direct infection from without 
through the medium of the respiratory mucous membranes or through 
the alimentary canal. The disease is observed more frequently among 
females than among males, by reason of the special liability of the 
female to puerperal infection. 

Pathological Anatomy. Ulcerative endocarditis is observed more 
frequently upon the left side of the heart than upon the right. It 
usually involves the substance of the valves, though it is occasionally 



DISEASES 7 Ml OSCARS >I IRCULATIl 

developed upon the parietal endocardium. The inflammatory process 
occurs usually upon that side of the valve that is directed against the 
blood current as it passes through the cavities of the heart. In the 
earliest stage of the disease there is a thin layer of exudation upon the 
endocardial membrane. If this be stripped off, a roughened surface. 
denuded of endothelium and surrounded ~ re I iened border, becomes 
visible. Later in the course of the disease the ulcerative process 
becomes more conspicuous. The neighborhood of the ulcer is infiltrated 
with the products of inflammation, accompanied by an abundant pro- 
liferation of pyogenic staphylococci and streptococci, with various other 
bacterial parasites, which, however, are not of a specific character, but 
are commonly observed in the course of septic inflammations. The 
adjacent tissues after a time may tindery ious changes that are 

produced by contraction, or by degenerations of a fatty or calcareous 
character. 

As a consequence of ulceration involving one of the surfaces of a 
valve, the weakened structure beneath the ulcer may bulge under the 

assure of the blood, and thus may be formed a valvular aneurism. 
» the mitral valve, or the tricuspid valve, such aneurisms m::~ - 
tain to considerab'T axe, in I their rupture will occasion an insufficiency 
of the ulcerated valvular curtain. Insufficiency of these valves may 
; a consequence of the destruction of their papillary 
muscles and chordae tendineae during the progress of an endocardial 
ulceration. 

The endocardial wall is sometimes infected by contact with an ulcer- 
Talvular surface, and may then become the seat of an extensive 
ulcer, which, if located upon the septum between the ventricles or be- 
tween the auricles, may open a communication between the ca 
ut: :l ::;: :s::e siies ;: :if L-ir:. 

As a consequence of the passage of the products of ulceration into 
the blood current, the course of the disease is complicated by the trans- 
fer of embolic masses horn, the heart into all parts of the body. Con- 
veyed by the nutrient arteries of the organ. .e cardiac 
circulation : and by their infectious character, they originate suppurative 
processes within t: nee of the heart, as well as in any or all of 
the other organs of the bo: I : is way the disease becomes compli- 
cated with the greatest varie:~ -ndary lera. The blood, 
moreover, undergoes the changes that chars its dissolution, and 
the capillary vessels lose their capacity for retaining their con ten:- - 
that hemorrhages are of frequent occurrence in the skin, or upon the 
mucous and serous membranes, and upon the retina. Erythematous 
and roseolous eruptions and minute capillarv embolisms are also some- 
times visible upon the surface of the body. The spleen is usually 
enlarged and softened, as happens in other infective d> on 

- }uence of the high grade of fever that occurs, the muscular tissues, 
especially in the heart, undergo fatty or w _ >udy 

swelling and granular degeneration of the cellular elements is commonlv 
:n all th^ 

■M juence of the numerous complications that 
mav occur in connection with acute ulcerative endocardi* ymp- 



ENDOCARDIAL DISEASES. 521 

toms of the disease may exhibit a great variety. Sometimes the attack 
is introduced with symptoms that remind one of Asiatic cholera, and 
death may speedily occur in a state of collapse. In other cases jaun- 
dice is present, which appears to be caused by dissolution of the red 
corpuscles of the blood and the transformation of their pigment into bile 
pigment, which discolors the skin. Three principal forms, however, 
are recognized. 

1. The typhoid form. In many cases the course of the fever and the 
general appearance of the patient closely resemble the physiognomy of 
typhoid fever. The fever is continuous ; pulse and respiration are 
somewhat quickened ; the abdomen is distended and tympanitic ; the 
spleen is enlarged ; rose spots appear upon the skin ; the patient lies 
in a state of indifference, or may exhibit the symptoms of mild delirium ; 
the eyes are partly closed ; the tongue is dry, brown, red at the tip 
and edges, and may become fissured and bleeding. There is diarrhoea ; 
the stools sometimes contain blood ; the urine is high colored, scanty, 
and even albuminous. Endocardial murmurs are not always present, 
and their absence renders the diagnosis still more difficult, especially 
as they are sometimes present in typhoid fever. The resemblance be- 
tween the two diseases, in short, is so great, that it may be impossible 
for a time to establish a positive diagnosis. The course of the disease 
may sometimes, however, throw light upon its nature through the 
development of embolic processes upon the skin or in the retina. 
Cutaneous embolisms may be recognized under the form of minute 
cutaneous hemorrhages surrounding a clear, yellow centre that is 
occupied by the embolic nucleus. Similar extravasations may be discov- 
ered upon the mucous membrane lining the oral cavity. Various erup- 
tions that resemble the exanthems of measles, scarlet fever, erythema, 
erysipelas, pemphigus, and pustular diseases may occur, and may some- 
times become the starting-point of gangrenous processes involving the 
skin. 

As a consequence of the extension of the embolic process to the 
eyes, an extravasation of blood may be observed beneath the conjunc- 
tiva or into the substance of the retina. Occasionally the whole eye 
may become involved by a universal purulent inflammation. 

In the acute form of the disease, death may occur within a few days ; 
subacute cases may linger for a number of weeks, and the chronic form 
may endure for many months. The symptoms that precede death may 
be those which characterize general infection of the system, or they 
may be those of heart failure, or of pericardial inflammation. Death 
may be the consequence of pulmonary or pleural complications, or life 
may terminate with symptoms of acute meningeal or cerebral dis- 
ease. 

2. The intermittent form. In this variety of the disease, the febrile 
movement closely resembles that of an intermittent malarial fever, 
sometimes assuming the quotidian, the tertian, or even the quartan type. 
There is great pallor, loss of appetite, and debility. The cardiac signs 
may be either entirely absent, or of a character that might be explained 
by the anaemic condition of the patient. In such cases the utterly 
negative result of treatment with quinine should arouse suspicion of the 



522 DISEASES OF THE ORGANS OF CIRCULATION 

true nature of the disease. The occurrence of embolic phenomena in 
connection with other organs, and the development of cardiac murmurs 
with other evidences of change in the structure of the heart, will assist 
the diagnosis. As the disease progresses the fever tends to become 
more continuous, and may finally pass into a typhoid form, with a fatal 
result like what has been already described. The duration of the dis- 
ease may reach many weeks or months before death occurs. 

3. In the third form of the disease the cardiac disorder is often 
quite thrown into the shade by the extent and severity of the morbid 
phenomena that are manifested in organs remote from the original 
centre of disease. In certain cases there is only complaint of such pal- 
pitation and weakness as is common in cases of ordinary anaemia. 
The physical signs are also such as usually correspond with that con- 
dition ; this negative condition may, however, undergo speedy trans- 
formation by the development of murmurs and changes that indicate a 
rapid extension of an ulcerative process involving the valvular structures 
of the heart. 

In other cases a purulent inflammation involving the serous cavities 
of the thorax or abdomen may by its course and symptoms mask the 
phenomena that are connected with the endocardial disease in which it 
had its origin. In like manner acute pneumonia, cerebro-spinal inflam- 
mation, purulent disorganization of the joints, and other septic pro- 
cesses, may originate in, and obscure the course of, ulcerative endocar- 
ditis. Embolic obstruction of the cerebral vessels sometimes occurs 
with the production either of hemiplegic symptoms or of local paralyses 
involving one or more of the cranial nerves. Psychical disturbances, to 
say nothing of the delirium that may accompany fever, have also been 
observed. 

Diagnosis. The preceding considerations sufficiently indicate the 
difficulties that attend the diagnosis of ulcerative endocarditis. In 
doubtful cases microscopical examination of the stools, or of blood 
drawn from the rose spots of fever, by the discovery of the patho- 
genic bacilli of typhoid fever, may serve to distinguish that disease from 
the endocardial inflammation. 

Prognosis. The disease is almost invariably fatal. Eichhorst 
reports only one recovery in the course of his extensive experience. 

Treatment. The treatment of the disease must be largely symp- 
tomatic, and in view of its great fatality cannot be very successful. 
The strength of the patient must be sustained by an appropriate diet, 
like that recommended for patients suffering with typhoid fever. Great 
prostration may be combated by the administration of camphor, musk, 
nux vomica, aromatic spirits of ammonia, and the compound spirits of 
ether. The patient must be kept quietly in bed, in order to avoid 
every unnecessary acceleration of the motion of the heart. An ice-bag 
may be laid over the heart, for the purpose of relieving pain and hin- 
dering the process of inflammation. Salicylate of sodium or salicylic 
acid may be given in doses of ten grains every hour until the physio- 
logical effects are produced. The drug may then be given less fre- 
quently, so long as it can be tolerated by the stomach. Alcohol should 
be freely administered, for the purpose of supporting the strength, and 



ENDOCARDIAL DISEASES. 523 

as an antidote to the poisons generated by the bacterial microorganisms. 
High fever may be relieved by the use of antipyrine or acetanilide in 
doses of five to ten grains every three or four hours ; but these drugs 
should be used with caution and for no long period of time. The action 
of the kidneys may be assisted by the administration, every two or 
three hours, of a tablespoonful of the infusion of digitalis with twenty 
grains of the citrate of potassium in aerated water. 

Verrucose Endocarditis — Endocarditis Verrucosa. 

Etiology. This form of endocardial inflammation owes its origin 
to the action of microbes upon the endocardium. No specific micro- 
organisms have been discovered as its cause, nor has it yet been ex- 
plained why in one case they produce ulcerative endocarditis, and in 
another the verrucose variety of the disease, though Fraenkel and 
Saenger have expressed the opinion that streptococcus pyogenes is 
principally concerned in the production of ulcerative endocarditis, 
while staphylococcus pyogenes aureus bears a similar relation with the 
verrucose form of the disease. 

Traumatic causes occasionally determine the incidence of inflamma- 
tion upon the endocardium ; but it more frequently results from the 
effects of cold or rheumatism or other infective diseases. Grout, mus- 
cular rheumatism, pneumonia, syphilis, and gonorrhoea must also be 
numbered among the causes of the disease. It is more frequent among 
males than among females, probably in consequence of the greater 
liability of the male sex to articular rheumatism. It is during the 
period between the twentieth and thirtieth years of life that it is most 
frequently observed. 

Pathological Anatomy. The characteristic changes consist in the 
production of endocardial vegetations, which are for the most part formed 
upon the curtains of the cardiac valves, along their lines of contact when 
forced against each other. These vegetations may vary in size from an 
excrescence that is just visible to a mass as large as a pea. By their 
aggregation they greatly deform the surface of the valve upon which 
they are placed, and they produce an obstruction of the blood current 
as it passes through the valvular aperture. The basis of the vegetation 
consists of the proliferating tissue of the valve, and the mass is still 
further enlarged by a fibrinous deposit from the blood itself. In recent 
cases the distinction between the basal layer and the superficial deposit 
may be easily demonstrated. As a consequence of the valvular lesion, 
chronic endocarditis almost invariably follows. The vegetations become 
organized, the valves upon which they are seated are thickened and 
gradually contract, with subsequent degeneration of a fatty or calcareous 
character. The injured valve frequently becomes anew the seat of fresh 
attacks of inflammation. 

The form of endocarditis occurs most frequently upon the left side 
of the heart, probably as a consequence of the fact that freshly oxy- 
genated blood affords the most favorable conditions for the multiplica- 
tion of the microorganisms which are concerned in the inflammatory 
process. When the disease occurs before birth it is seated upon the 



524 DISEASES OF THE ORGANS OF CIRCULATION. 

right side of the heart, which then contains the most highly oxygenated 
blood. The vegetative process is manifested usually upon the mitral 
valve ; next in order of frequency, upon the aortic valve ; next upon 
the tricuspid valve ; then upon the pulmonary valve ; lastly upon the 
walls of the heart. When it attacks the parietes it is more frequently 
observed in the auricles than in the ventricles. 

As a consequence of extensive vegetation within the cavities of the 
heart embolic masses may become detached, and are swept by the cur- 
rent of the blood into the arteries of the extremities and organs of the 
body. In this way may be produced the phenomena of arterial obstruc- 
tion with formation of infarcts in the organs that are involved, e.g., 
the brain, spleen, kidneys, and other organs. The consequences of 
these embolic obstructions are chiefly of a mechanical character, in 
this respect differing from the suppurative processes that result from 
the infective nature of the emboli that originate in ulcerative endo- 
carditis. 

Symptoms. Subjective symptoms are often either absent, or are of 
an exceedingly vague and indefinite character. Sometimes the patient 
complains of discomfort in the precordial region, or of dyspnoea, or of 
palpitation accompanied by pain in the epigastric region that sometimes 
extends into the left shoulder and down the left arm. So frequent is 
the connection between the affection of the heart and acute articular 
rheumatism that the possibility of its occurrence should always be 
remembered in such cases. The only positive symptoms of the endo- 
cardial disease are furnished by the valvular defects which grow out of 
its existence. For this reason it is usually impossible to recognize the 
existence of parietal endocarditis or of minute valvular vegetations. 
Only when the auscultatory signs of valvular disease can be recognized 
as originating in the course of rheumatism or other acute disease, 
can the observer feel confident of the development of acute endo- 
carditis. 

Since it is the mitral valve that is most frequently involved, ausculta- 
tion first detects a systolic murmur at the apex of the heart, which, if 
not explained away by the existence of anemic or feverish conditions 
of the blood, affords a valuable sign of endocardial inflammation. The 
participation of other valves in the disease will be indicated in like 
manner by murmurs that correspond with their location. (Fig. 109.) 
As the disease progresses and as the valves become damaged in greater 
degree, various murmurs may arise in accordance with the occurrence 
of obstruction or regurgitation of the blood current. The import of 
these sounds will be more fully considered in connection with the dis- 
eases of the different cardiac valves. 

The association of pericarditis with endocarditis often obscures the 
diagnosis of the latter inflammation. It frequently happens that the 
endocardial murmurs, which are at first distinctly audible, are com- 
pletely overwhelmed by the intercurrence of pericardial inflammation. 

The occurrence of arterial obstruction as a consequence of endocar- 
ditis may be easily recognized by the sudden incidence of violent pain 
in the affected part. In this way renal embolism may be recognized by 
hematuria and by the existence of pain in the upper portion of the 



ENDOCARDIAL DISEASES. 



525 



loins, frequently accompanied by vomiting and febrile reaction. Splenic 
embolism is indicated by pain in the left hypogastrium. Cerebral em- 
bolisms are indicated by disturbances of consciousness, sensation, and 
the power of motion, often of an hemiplegic character. Obstruction of 



Fig. 109. 




Areas of cardiac murmurs (Gairdner for the areas, and Luschka for the anatomy). 
The outlines of organs, which are partially invisible in the dissection, are indicated by 
very fine dotted lines, while the areas of propagation of valvular murmurs have been 
roughly marked by additional coarser and more visible dotted lines, the character of the 
dots being different in each of the four areas. A capital letter marks each area, viz. : 
A. The circle of mitral murmurs, corresponding with the left apex. B. The irregular 
space indicating the ordinary limits of diffusion of aortic murmurs, corresponding mainly 
with the whole sternum, and extending into the neck along the course of the arteries. 
C. The broad and somewhat diffused area occupied by tricuspid murmurs, and correspond- 
ing generally with the right ventricle. D. The circumscribed circular area over which 
pulmonic murmurs are commonly heard loudest. 

Reference letters : r.au. Right auricle, a.o. Arch of aorta, o.i. The two innominate 
veins, r.c. Vena cava descendens. p. Pulmonary artery. I. an. Left auricle. I. v. Left 
ventricle, r. v. Right ventricle. 



the vessels in the extremities is indicated by the occurrence of severe 
pain in the affected part, with disappearance of arterial pulsation, and 
the development of coldness and discoloration of the surface, with 
great difficulty of motion in the affected limbs. Cutaneous embolism 



DISEASES 31 THE :^}AV; >f 3IRCULATIOIT. 

produces the phenomena of erythema nodosum. A slight elevation of 
the internal temperature of the body is usually observed, even though 
I portion- is ly refiigei ited. 

Thr i that endocar- 

ditis persist through I me merged in the phenomei- 

chronic endo: aease. 

Treatment. The :ce of the disease upon previously ex- 

sting conditions, renders ir evident that no prophylactic treat- 

ment is of any avail, unless as such be considered the treatment of the 
primary ini ... ^Vhen the recent occurrence of endocardial inflam- 
mation has been recognised, it will be found useful to cover the 
rdial region of the chest with soft folds of light flannel, upon 
which should be laid an ice-bag of moderate weight, that must be re- 
filled as often as the ice is melted. A febrile condition calls for the 
administration ::::.:::; yrine. acetanilide. or \ i loses ifive 

grains every four hours. In rheumatic inflammation, salicylate 
of sodium maybe substituted in doses often to fifteen _ as -very 
hour until the physiological effects are produced. It should then be 
given less frequently. Rapid movement of the heart may be moderated 
by the administration :: ligitalis and the ;■::: ite : >1 ssium, 
ommended in the last chapter. Chronic endocarditis with valvular 
disease may be treated with iodide of potassium «five to ten grains three 
times a day), or the syrup of the iodide of iron (half a teaspoonful three 
times a ds 

Chronic Endocarditis — Endocarditis Chronica. 

Etiology. When ndocarditis originates in theverru 

form of the disease, it is e vi lent that their rimary causes must be the 
same. Besides these causes may be enumei ted art .: -sclerotic ch;. _ - 
that occur at an advanced period of life Chj nic nephritis, gout, dia 

arthritis deformans, lead poisoning, chron Lcoholism, and syphilis, 
may also be enumerated among the causes of the dia m By some 
observers it has been thought that v ... are made 

by raw recruits on the sion of hard marches during war-time, may 

produce a chronic inflammation of the endocardium. 

Pathological Anatomy, i - jf inflammation is indicated by 

thickening and prominence of the affected portion of the endocardial 

In old cases the inflamed tissue may become calcified or 

:is are invaded by the disease they 
become contracted and crumpled. Atheromatous changes are not 
mmon. 
When the 8 - are thus invaded, they are either con- 

verted in: struction to the passage of the blood into the ar: 

- their inability to close the arterial opening they promote a 

the blood into the cardiac ventricle. In this way 
various disturl : the circulation have their origin at the entrance 

of the aorta or of the pulmonary artery. 

When the curtains of the ventricular valves are invaded, the - - 
usuallv eo to the chordae tendine;e and the papillary mu- 



ENDOCARDIAL DISEASES. 527 

Various deformities may thus arise, and the auriculo-ventricular pas- 
sages may become contracted into mere buttonhole-like orifices. 

The situation of the disease corresponds with what has already been 
indicated for verrucose endocarditis. The disease may extend to the 
muscular substance of the heart, producing chronic myocarditis. Mitral 
inflammation is most common during early and middle life; in old age 
the disease more frequently attacks the aortic valve, in consequence of 
the greater predisposition to arterio-sclerotic changes during advanced 
life. 

The disease persists in its chronic form till death. It is also ex- 
tremely prone to acute exacerbations or relapses. As a consequence of 
the valvular deficiencies that are produced, the heart becomes hyper- 
trophied and dilated. 

Symptoms. Since chronic inflammation can only be recognized 
through the injuries which it entails upon the valvular structures of the 
heart, its symptoms become identical with those which characterize 
valvular diseases and imperfections. It is therefore advisable to pro- 
ceed to a consideration of the 

Diseases of the Cardiac Valves. 

Etiology. Cardiac valvular deficiency is usually the result of endo- 
cardial inflammation, but occasionally it may be produced by the 
rupture of a valve through sudden violent muscular exertion. Some- 
times the valvular defect is caused by tumors that encroach upon the 
heart or develop in its w T alls. Valvular aneurisms and cardiac throm- 
bosis may also obstruct the functions of the valves. Fatty degeneration 
of the papillary muscles, and nervous prostration, may also occasionally 
interfere with their function. It usually happens that only a single 
valve is involved, but two or more may be aflected at the same time. 
The mitral valve is generally the seat of deficiency, or the mitral and 
aortic valves may both be simultaneously aflected. The defect of the 
mitral valve, or insufficiency of the aortic valve, may also be associated 
with insufficiency of the tricuspid valve. It is a very uncommon thing 
to find three or four of the cardiac valves involved at the same time. 

Heredity plays a somewhat important part in the development of 
valvular diseases. They are most commonly met with among laboring 
people during middle life. 

Pathological Anatomy. The pathological changes that are pro- 
duced by valvular diseases are, in the first place, local alterations that 
are manifested in the structures of the heart, and, in the second place, 
the changes that result in distant organs by reason of retardation of the 
blood current, or through the results of embolism. 

In addition to the pathological changes within the heart that have 
l)een already described upon a preceding page, by which may be pro- 
duced either an insufficiency of the valvular curtains themselves, or a 
narrowing of the endocardial passages, it must not be forgotten that the 
muscular structure of the organ may undergo hypertrophy, or, finally, 
atrophy with dilatation of the heart. The pericardium may also in- 
dicate a condition of inflammatory change ; and the intinia of the aorta 
may exhibit fatty and atheromatous degenerations. 



028 DISEASES OF THE ORGANS OF CIRCULATION. 

The blood is usually darker, thinner, and less richly furnished with 
albuminous constituents than in a state of health. The veins are over- 
distended, and the serous cavities contain an excess of liquid which 
may become turbid or colored with haemoglobin in severe cases, at- 
tended by dissolution of the blood. The respiratory passages exhibit a 
catarrhal condition. The lungs and the glottis may become cedema- 
tous. The capillary vessels of the lungs become varicose, and the 
organs themselves are frequently loaded with pigment, constituting 
what is called brown induration of the lungs. As a consequence of re- 
tarded pulmonary circulation, the minute bloodvessels of the respiratory 
organs may undergo fatty degeneration, with subsequent interstitial 
hemorrhage, which must be distinguished from the hemorrhagic infarcts 
that are produced by embolism. 

The spleen is sometimes enlarged ; its capsule becomes thickened 
and occasionallv adherent to the neighboring organs. Through in- 
crease of its connective tissue, it is denser and firmer than is natural, 
and it may also contain embolic infarctions. 

The mucous membrane of the stomach and intestines exhibits a 
catarrhal condition. The hemorrhoidal veins of the rectum are greatly 
distended. The liver is usually enlarged, filled with blood, and of a 
dark-purple color. The central veins of the acini are greatly distended 
and contrast strongly with the lighter, sometimes fatty, peripheral por- 
tions of the structure, producing the characteristic appearances of the 
so-called nutmeg liver. Microscopical examination frequently reveals 
an atrophied condition of the liver, caused by the increase of blood 
pressure in the capillary vessels. In chronic cases, the connective tis- 
sue of the organ becomes increased in amount, and is finally contracted 
to a degree that effects a reduction in the size of the organ, with a 
roughening of its surface similar to that which is discovered in cirrhosis 
of the liver. The mucous surface of the gall bladder exhibits a 
catarrhal condition, with consequent dilution of its biliary contents. 

The kidneys also exhibit a hyperbaric enlargement. The stellate 
veins upon the surface of the organ are greatly distended, its capsular 
investment remains transparent and is easily stripped off from the 
underlying tissue. The pyramidal portion of the kidney is of a deep- 
purple color, in strong contrast with its cortical portion. The epithelium 
and the uriniferous tubules exhibit the appearances of cloudy swelling 
and incipient catarrhal inflammation. In chronic cases, the epithelial 
cells have undergone fattv degeneration. The connective tissue in all 
parts of the kidney becomes increased and, finally, contracted, with 
consequences similar to those observed in primary contraction of the 
kidney. Embolic and concomitant infarctions are also sometimes ob- 
served. 

Similar changes of a hyperbaric and hemorrhagic character may be 
discovered in the genito-urinary organs and in the pancreas. 

The cerebral vessels and sinuses are distended with blood ; a section 
of the brain exhibits* numerous bleeding-points. 

The meningeal cavities and the ventricles of the organ are filled with 
a serous liquid, and there is an cedematous condition of the pia mater. 



ENDOCARDIAL DISEASES, 



529 



The meninges and the ventricular ependyma are frequently clouded 
and thickened. 

Symptoms. Before proceeding to a consideration of the general 
symptoms of valvular disease of the heart, it will be found advantageous 
to pass in review the symptoms and signs that are characteristic of 
particular valvular defects, by which, in fact, the local disease can alone 
be recognized. The immediate eifects exhibit themselves in changes 
of the cardiac structure, producing either hypertrophy or dila- 
tation of the affected portion of the heart. So long as the hyper- 
trophied muscle can overcome the consequences of valvular deficiency, 
there is effectual compensation of the defect ; but when, through im- 
perfect nutrition, such hypertrophy no longer exists, the cavities of 
the heart become enlarged through dilatation and thinning of their 
walls. Compensation is no longer effected, and the blood current is 
retarded, with consequent development of universal disorder in all 
parts of the body. 

Aortic Insufficiency. 

Insufficiency of the aortic valve may consist in a diseased condition 
of one or more of its cusps, by which it is rendered incapable of com- 
plete closure during cardiac diastole. A portion of the blood within 
the aorta finds its way back into the ventricle, during the dilatation of 
that cavity, with the production of a murmur as it assumes a vortical 
movement through its contact with the ventricular walls, and its en- 
counter with the simultaneous current of blood from the auricle into 

Fig. 110. 




Pulse of aortic regurgitation. Pressure, 2| oz. (Finlayson.) 
Fig. 111. 




Pulse of aortic regurgitation. Pressure, 2 oz. (Finlayson.) 

the ventricle. As a consequence ot this excessive influx of blood, the 
left ventricle is compelled to dilate beyond its ordinary capacity. A 
larger amount of blood must therefore be propelled into the aorta dur- 
ing the systolic contraction of the heart. Constant repetition of this 
excessive activity occasions hypertrophy of the left ventricle. 

34 



530 DISEASES OF THE ORGANS OF CIRCULATION 

As a consequence of this increased influx of blood, the arterial sys- 
tem becomes over-distended : but the rapid discharge of blood into 
the capillary system, and its regurgitation into the left ventricle, cause 
a rapid subsidence of that distention during the period of cardiac dias- 
tole. Hence the pulse is full and quick, and the sphygmographic 
curve is characterized by rapid ascent and speedy descent. 

Inspection of the thorax reveals a prominence of the precordial re- 
gion produced by the enlargement of the left ventricle. When the 
thoracic -walls are thin and unincumbered with fat. the cardiac impulses 
can be easily perceived in the neighborhood of the left mammary line. 
In chronic cases with great enlargement, the cardiac impulses may be 
observed even as far as the axillary line. Strong systolic impulses 
may sometimes be felt in the second intercostal space upon the right 
side of the sternum, as a consequence of dilatation of the ascending 
aorta, and they may also be traced into the carotid arteries and super- 
ficial vessels of the head. 

Palpation. If the hand be applied to the precordial region, a 
diastolic fremitus or purring sound can sometimes be perceived over the 
aortic valve. Similar sensations may be experienced in connection 
with the abdominal aorta and other large arterial vessels throughout 
the body. 

Percussion over the heart reveals enlargement of the left ventricle. 
causing an extension of dulness beyond the left mammary line and 
sometimes reaching as far down as the eighth or ninth rib. The posi- 
tion of the right border of the heart remains unchanged. 

Auscultation discovers a diastolic murmur at the base of the heart. 
Seldom loudest in the second intercostal space upon the right side, it is 
usually most audible over the middle of the sternum and near its left 
border, for the reason that the vortical movements of the blood by which 
it is produced occur below the aortic valve and within the left ventricle. 
These aortic regurgitant murmurs vary in quality and intensity, being 
sometimes loud and deep, or of a musical character. Loud murmurs 
overwhelm the diastolic sound of the heart, but when they are soft and 
faint, the diastolic sound may be perfectly audible along with the 
regurgitant murmur. The first (systolic: sound at the apex of the 
heart does not usually undergo any great modification, though it may 
become associated with murmurs that are transmitted from the aorta, 
where they are sometimes originated without the occurrence of actual 
stenosis. As a consequence of ventricular hypertrophy, the first sound 
may become widely diffused and less clearly defined than in the normal 
lition. The second (diastolic) sound of the heart is by no means 
abolished at the apex, as at first might have been anticipated. The 
intact pulmonary valve and the collision of the regurgitant blood from 
the aorta against the ventricular wall, suffice to maintain, with consider- 
able integrity, the second sound at the apex during cardiac diastole. 

Various murmurs become audible in the larger arteries if they are 
subjected to auscultation. 

It occasionally happens that the injured valve is healed, and that 
recovery takes place, with complete disappearance of every sign of 



ENDOCARDIAL DISEASES. 531 

previous disease. But far more frequently the valvular insufficiency is 
transformed into aortic stenosis by the persistence of inflammation and 
exudation upon the valvular cusps. 

Aortic Stenosis. 

As a consequence of valvular disease producing a reduction of the 
diameter of the aortic entrance, the blood current encounters great 
opposition to its passage from the left ventricle of the heart into the 
aorta. This produces dilatation and hypertrophy of the ventricle, 
though not to the extent that occurs as a consequence of aortic valvular 
insufficiency, for the reason that the ventricle is not compelled to receive 
and to propel the excess of blood that regurgitates from the aorta 
through insufficiency of the semilunar valve. 

As the blood passes the point of constriction and is forced during car- 
diac systole into the dilated aorta, it is thrown into a series of vortical 
movements, by which a systolic murmur is originated just beyond the 
constricted entrance to the vessel. Thus is produced the characteristic 
aortic murmur that coincides with the first sound of the heart. 

In consequence of the difficulty that accompanies the propulsion of 
blood from the left ventricle, the distention of the aorta and its branches 
is less than normal, and the time necessary for emptying the ventricle 
is greater than is needed in the normal condition of the valve. Hence 
the pulse is slow and small. 

Inspection often indicates a diminution or absence of the cardiac 
impulse. If the left ventricle is considerably hypertrophied there is 
visible, however, a strong and heaving impulse at the apex, which beats 
to the left and downward from the normal point. The heart is, how- 
ever, never as greatly enlarged and displaced to the left as in the 
hypertrophy that follows aortic regurgitation, consequently the precor- 
dial region is less likely to become prominent. 

Fig. 112. 




Aortic stenosis in a patient aged twenty-six. Pressure, 5i oz. Loud, rough systolic 
murmur at aortic cartilage; pulse small but hard; evidence of moderate ventricular 
hypertrophy. (Finlayson.) 

Palpation frequently discovers a systolic fremitus over the base of 
the heart, and particularly in the second intercostal space upon the right 
side of the sternum. It may occasionally be observed as far as the 
apex of the heart. The pulse is small and incompressible; its duration 
is prolonged, and it develops somewhat later than the cardiac systole. 
The sphygmographic curve exhibits a tardy formation of the line of 
ascension, with gradual development of the descending curve. (Fig.112.) 

Percussion indicates an increase of cardiac dulness downward and 
to the left. 



532 DISEASES OF THE ORGANS OF CIRCULATION. 

Auscultation discovers a systolic murmur which is most audible in 
the second intercostal space on the right side. It may sometimes be 
heard all over the cardiac region and in the large arteries of the neck, 
and even upon the posterior surface of the thorax. It can be heard some- 
times at a considerable distance from the body of the patient. The 
intensity of the sound is, however, no indication of the extent of the 
disease by which it is caused, since it has been discovered that noisy 
murmurs may be associated with slight anatomical changes. 

The second aortic sound is very faint or entirely absent, in conse- 
quence of the diminished tension of the blood within the aorta. The 
other sounds of the heart exhibit no change, though they may be 
obscured sometimes by the strength of the aortic murmur. 

Mitral Insufficiency. 

In consequence of insufficiency of the mitral valve, the systolic con- 
traction of the heart causes a regurgitation of blood from the left ven- 
tricle into the left auricle, which thus is compelled to receive blood 
from two sources, the ventricle and the pulmonary veins. The auricle 
must therefore become dilated in order to accommodate this excess ; but 
by reason of the pressure that is imparted to the blood as it regurgitates 
from the ventricle, the discharge of blood from the pulmonary veins is 
greatly retarded, and they remain in a condition of distention. The 
capillary vessels within the lungs are thus over- distended, a condition that 
hinders the progress of blood through the branches of the pulmonary 
arteries. This occasions opposition to the flow of blood out of the right 
ventricle, which must therefore become dilated and hypertrophied. In 
like manner, the right auricle is hindered from emptying its contents easily 
into the right ventricle, the blood current is pushed back into the vense 
cavse, and the w T hole venous system remains in a condition of permanent 
over-distention, while upon the opposite side of the circle the aorta 
and the arterial system receive less than the normal supply of blood. 

Along with these changes the left ventricle must become somewhat 
dilated and hypertrophied as the increasing vigor of the right side of 
the heart tends to compensate the insufficiency of the mitral valve by 
urging the blood with increased force through the lungs into the left 
auricle. 

During cardiac systole, as the blood regurgitates through the insuf- 
ficient mitral valve it meets the opposing current from the pulmonary 
veins, and it is thrown into a vortical movement within the cavity of 
the left auricle. A systolic murmur is thus produced, which coincides 
with the first sound of the heart, and is most distinctly audible at its 
apex. 

Inspection indicates prominence of the cardiac region when there is 
considerable hypertrophy of the right ventricle. This hypertrophy must 
be very considerable, to displace the apex from its normal position. 
When both ventricles are hypertrophied, there may then be considerable 
displacement of the cardiac impulse in a downward and outward direction. 
General diffusion of the cardiac impulse may be discovered over the 
lower portion of the sternum in cases of considerable hypertrophy of 



ENDOCARDIAL DISEASES. 533 

the right ventricle. If the pulmonary artery is greatly distended, a 
systolic impulse may be perceived in the second intercostal space upon 
the left side of the sternum. If the foramen ovale remains open, the 
veins in the neck pulsate visibly by reason of the retrograde impulse 
propagated directly from the left ventricle through the insufficient 
mitral valve and the patulous foramen into the right auricle and the 
vence cava?. 

Palpation sometimes discovers a fremitus over the apex of the heart, 
but this is frequently perceptible only after violent muscular exertion, 
or during a recumbent position upon the left side. The cardiac impulse 
is unusually evident along the right side and lower extremity of the 
sternum. Pressure with the finger in the second intercostal space upon 
the left side of the sternum discovers an impulse which alternates with 
the apex beat. It corresponds with the diastolic closure of the pulmo- 
nary valve, and is consequent upon hypertrophy of the right ventricle. 
The pulse at the wrist is generally normal, though in advanced stages 
of the disease, as the compensatory vigor of the ventricular muscle 
gives way, it may become irregular. The sphygmographic indications 
exhibit nothing that is specially characteristic or diagnostic of valvular 
disease. (Fig. 113.) 

Fig. 113. 




Tracing from a case of mitral regurgitation, showing the pulse irregular in force and 
rhythm. (Finlayson.) 

Percussion indicates an extension of cardiac dulness toward the 
right, when the right ventricle alone is hypertrophied. Enlargement 
of both sides of the heart is indicated by an extension of the area of 
dulness in every direction. 

Auscultation reveals a systolic murmur at the apex of the heart, 
which also may be heard frequently over the region of the tricuspid 
and pulmonary valves. This murmur is often transmitted to the left 
and can be heard even at the angle of the scapula. The diastolic 
sound at the pulmonary valve is considerably accentuated as a con- 
sequence of an increase of blood pressure within the pulmonary artery 
that is produced by hypertrophy of the right ventricle. 

Cases of mitral insufficiency seldom persist without the development 
of mitral stenosis through contraction of the auriculo-ventricular ring. 
Complete recovery has been occasionally noted by competent observers. 

Mitral Stenosis. 

Contraction of the auriculo-ventricular passage effects a hindrance 
to the transit of blood from the left auricle into the left ventricle, hence 
a considerable increase of blood pressure in the pulmonary circulation 



534 DISEASES OF THE ORGANS OF CIRCULATION. 

with its remote effects upon the right side of the heart. Hence, also, 
tardy filling of the left ventricle and diminution of blood pressure in 
the arterial system. As a consequence of this condition the right ven- 
tricle becomes dilated and hypertrophied, while the left ventricle remains 
but little changed. The blood, streaming slowly from the auricle into 
the left ventricle during cardiac dilatation, produces a diastolic murmur 
that is developed at the auriculo-ventricular opening, as the left ven- 
tricle gradually fills itself. This murmur is therefore most distinctly 
audible at the apex of the heart during the interval between the second 
sound and the first. 

Inspection brings to light a prominence of the cardiac region pro- 
duced by enlargement of the right ventricle. Increase of blood pres- 
sure in the pulmonary artery is indicated by pulsation in the second 
intercostal space upon the left side, and there is diffusion of the cardiac 
impulse along the right border of the sternum. The apex beat is not 
displaced unless there be hypertrophy of the left ventricle or unusual 
enlargement of the right side of the heart. 

Palpation reveals a presystolic fremitus over the apex. It. however, 
may require violent muscular exertion or the recumbent position upon 
the left side to develop this sensation. The increased cardiac impulse 
along the right border of the sternum can be distinctly felt with the 
hand. The pulse at the wrist is usually small and compressible, and 
is frequently irregular. The sphygmographic pulse curve exhibits 
nothing of a diagnostic character. (Fig. 114.) 

Fig. 114. 






Mitral stenosis. Patient aged sixteen: pulse 100; pressure, three ounces: well-marked 
auricular systolic murmur and thrill. , Finlayso.h.) 

Percussion indicates the extension of cardiac dulness to the right, 
as a consequence of hypertrophy of the right ventricle. 

Auscultation usually renders audible at the cardiac apex a presys- 
tolic murmur, which ceases at or just before the commencement of the 
systolic sound of the heart. There is no murmur with the first or 
second sounds, nor during the brief interval between. The pathological 
murmur occurs during the longer interval between the second (diastolic) 
sound and the first (systolic) sound. 

As a consequence of right ventricular hypertrophy the second sound 
of the heart is accentuated over the r- _ the pulmonary artery. 

The first sound at the cardiac apex is frequently accentuated by reason 
of the increased vibration of the curtains of the mitral valve. The 
second sound may be sometimes absent, though it is reinforced 
sionally by accentuation of the sound that is produced by closure of 
the pulmonary valve. 

Stenosis of the mitral valve is frequently complicated with insuffi- 



ENDOCARDIAL DISEASES. 535 

ciency of the same valve. In such cases the symptoms of stenosis may 
be quite obscured by those of insufficiency. The prognosis of the dis- 
ease is still more unfavorable than in simple mitral insufficiency, yet 
occasionally recovery has been observed. 

Insufficiency of the Pulmonary Valve. 

Insufficiency of the semilunar valves at the entrance of the pulmonary 
artery permits regurgitation of the blood from the pulmonary vessel 
into the right ventricle during cardiac diastole, with the consequent 
production of a diastolic murmur in the conus arteriosus. The right 
ventricle becomes charged during diastole with blood that is regurgi- 
tated from the pulmonary artery in addition to the usual amount 
received from the right auricle. Dilatation and hypertrophy of the 
ventricle are the necessary consequences of this condition. 

Inspection of the cardiac region discovers the characteristic appear- 
ances that accompany enlargement of the right heart. 

Palpation reveals a similar diffusion of the cardiac impulse toward 
the right, and also a diastolic fremitus in the second intercostal space 
upon the left side of the sternum and over the lower portion of the 
breastbone. The cardiac impulse exhibits no modification either at 
the apex or in the radial pulse. 

Percussion indicates increased dulness over the right heart. 

Auscultation discovers a diastolic murmur with the second sound 
of the heart in the second intercostal space upon the left side. It 
is also frequently audible over the lower portion of the sternum and at 
the entrance of the aorta. The second sound of the heart is inaudible 
over the pulmonary artery, except in those cases in which it is con- 
ducted from the aortic valve, or in which a portion of the pulmonary 
valve has escaped injury. 

Insufficiency of the pulmonary valve is a very rare disease, yet it is 
associated sometimes with stenosis of the valve. It is sometimes the 
consequence of congenital defects, or it may exist as a consequence of 
injuries, arterio-sclerosis, rheumatism, or primary valvular disease in 
the left heart. 

Stenosis of the Pulmonary Valve. 

In stenosis of the pulmonary valve the blood meets with opposition 
to its passage during cardiac systole, from the right ventricle into the 
pulmonary artery. This produces dilatation and hypertrophy of the 
right ventricle. The pulmonary artery fills slowly, and the blood 
pressure within its cavity is less than normal. A systolic murmur, in 
consequence, arises at the entrance of the artery. 

Inspection indicates prominence of the heart region, especially along 
the left border of the sternum. Systolic vibration may be noted over 
the lower portion of the breastbone. The impulse at the apex is 
scarcely perceptible. Epigastric pulsation can be often seen. 

Palpation discovers a systolic fremitus, most perceptible over the 
second intercostal space upon the left side. The pulse at the wrist ex- 
hibits no marked change. 



US V CIRCULATION 



Prcussion shows an extension of cardiac dull, ese I wards the right. 

Auscultation reveal- systolic murmnr in the second intercostal 
space upon the left side. It is sometimes lond and musical, and may 
be heard all over the cardiac region. The second sound of the heart is 
absent, or very weak, over the region of the pulmonary artery, by rea- 
son of the diminution of blood pressure in that vessel. The other heart 
sounds may remain without change. 

^rnosis of the pulmonary valve : ; very rare occurrence among 
adults, unless it be of congenital origin, when it may be associated with 
other defects of ante-natal date. 



Ins^nicieiicv of the Tricuspid Valve 

1\ ?utjheiency of the tricuspid valve permits the regurgitation of blood 
from the right ventricle into the right auricle during cardiac systole. 
This produces dilatation and hypertrophy of the right auricle and the 
right ventricle. By the regurgitative process a systolic murmur is pro- 
duced in the right auricle, and the blood is further driven back in: : the 
vena? cavae with the consequent production of pulsation in the large 
veins in the neck and trunk of the bodv. 

Inspection. The cardiac region . frequently appears prominent. 
There is a diffuse impulse over die right heart, but the most conspic- 
uous visible signs are connected with the large veins in the neck. 
::nued dilatation of these vessels occasions insufficiency of their 
valves, and each regurgitant blood wave produces a visible impulse 
even as far as the facial, temporal, and auricular veins As the 
of venous dilatation progresses, similar pulsations may be discovered in 
all the principal veins of the body and extremities. Under these cir- 
cumstances the liver may be seen to pulsate like an aneurism. 

J 7 potion indicates a diffusion of the cardiac impulse toward the 
Left, :.n& sometimes systolic fremitus may be felt over the inferior por- 
tion of the sternum. The radial artery is imperfectly filled at the 
and the spbygmographie curve indicates diminished blood pressure and 
a sluggish movement of the arterial walk 

Percussion indicates considerable increase of cardiac dulness toward 
the right. 

A puliation renders audible a systolic murmur along the right 
border of the sternum between the second and fourth costal carti. _ 
D 8 sometimes audible over the entire heart, and even at a considerable 
distance from the thorax. The second sound, at the entrance of the 
pulmonary artery and over the right ventricle, is faint, by reason of 
the reduction of blood pressure in that vessel. 

i-omplicated insufficiency of the tricuspid valve is of exceed: _ 
rare occurrence. It may be present as a sec:nia uence of 

valvular disease upon the left side of the heart through enlargement of 
the organ and consequent distention of the right auriculo-ventricular 
passage, rendering it impossible for the valve to close sufficiently the 
enlarged opening. 



ENDOCARDIAL DISEASES. 537 



Stenosis of the Tricuspid Valve. 

Uncomplicated stenosis of the tricuspid valve scarcely ever occurs. 
It is generally associated with valvular disease of the left heart. It 
occasions dilatation and hypertrophy of the right auricle, with increased 
pressure in the vense cavae, and a reduction of pressure in the right 
ventricle and in the pulmonary artery, as well as throughout the left 
heart and the entire arterial system. Obviously if a murmur be audi- 
ble it must be either diastolic, or presystolic and audible over the region 
of the tricuspid valve. There will also be an increase of cardiac dul- 
ness over the right auricle, and a diminution of the second sound at the 
entrance of the pulmonary artery. 

Stenosis of the Heart. 

As a consequence of inflammation of the connective tissue in the 
myocardium, the conus arteriosus upon either side of the heart may 
become diminished in diameter with consequent hindrance of the free 
passage of blood from the ventricle into its corresponding artery. This 
constitutes what is called stenosis of the heart. The symptoms are 
those that are produced by valvular stenosis, with the exception that in 
cardiac stenosis the second sound is fully formed and sharply defined, 
thus indicating integrity of the valvular structures, a condition which 
does not exist in ordinary valvular stenosis. 

Associated Defects of the Cardiac Valves. 

Since each one of the cardiac openings may become the seat of either 
insufficiency or stenosis of its valve, and since two or more of those 
structures may, at the same time, exhibit morbid change of function, 
the number of combinations and permutations that are possible is very 
great. A combination of insufficiency and stenosis may be presented 
by the same valve, and sometimes may admit of recognition during life. 
In other cases, the signs of either insufficiency or stenosis may be 
developed so extensively that the associated condition remains undis- 
covered. In certain instances the association of the two defects suffices 
for their compensation, so that the cardiac circulation is not materially 
disturbed. A good example of this is furnished sometimes by the con- 
currrence of aortic stenosis with insufficiency of the aortic valve. Dur- 
ing a cardiac diastole the existence of stenosis prevents any considerable 
regurgitation of blood from the aorta, and during contraction of the 
hypertrophied left ventricle the aorta is protected from over-distention 
by the narrowing of its entrance. In like manner, stenosis of the left 
auriculo -ventricular opening may obviate the evil consequences of asso- 
ciated insufficiency of the aortic valve. But, on the contrary, stenosis 
of the aortic valve causes increase of the unfavorable conditions that 
are caused by the associated existence of mitral insufficiency. The 
arterial system receives less blood, and the venous system becomes 
more excessively distended than would be possible with mitral insuf- 
ficiency alone. 



538 DISEASES OF THE ORGANS OF CIRCULATION. 

The general symptoms of valvular disease of the heart depend 
upon the changes that are produced in the circulation of the blood. 
So long as the nutrition of the heart is sufficient to enable its hyper- 
trophied muscles to overcome existing obstacles to the progress of the 
blood, no disturbances of the health will occur, but so soon as compen- 
sation fails, disturbances of circulation will arise and may extend to 
the most distant organs of the body. The exciting causes of such com- 
pensatory failure may be found in every form of extraordinary muscular 
exertion and fatigue. Worry and care, the abuse of tea, coffee, and 
alcohol, exercise an unfavorable influence. Pregnancy, childbirth, 
lactation, imperfect nutrition, intercurrent diseases, and the renewal 
of endocardial inflammation, all exercise the most unfavorable influence 
upon the functional vigor and efficiency of the heart. 

By reason of the tendency of valvular disease of the heart to produce 
disorder in other organs of the body, it becomes a matter of the highest 
importance to avoid the misleading indications derived from such dis- 
turbances by which the superficial observer may find his attention 
diverted from the real source of disorder. 

So long as valvular defects are sufficiently compensated by healthy 
hypertrophy of the cardiac muscles the patient may experience no sub- 
jective symptoms, or they may become apparent only when the heart 
is roused to unusual activity by violent exertion or by excess in eating 
and drinking, or by the recumbent position upon the left side. Not 
unfrequently, however, does the patient complain of a feeling of con- 
striction about the thorax, or of difficulty in breathing, or of other 
indefinite sensations of discomfort. The occurrence of valvular disease 
in early life is liable to occasion imperfect physical development. 
Sometimes as a consequence of defective nutrition, a high grade of 
cachexia becomes apparent. The tips of the fingers may become 
clubbed and of a claw shape, by reason of these errors of nutrition. 

A cyanotic condition of the skin is usually evident. This corresponds 
in degree with the amount of obstruction to the pulmonary circulation, 
and is, therefore, more commonly connected with mitral disease than 
with aortic. 

The skin is not unfrequently jaundiced to a greater or less degree. 
This condition is usually of gradual development and chronic duration, 
but it sometimes originates suddenly as a consequence of embolic pro- 
cesses in the liver. 

The minute veins in the cheeks and upon the nose are frequently 
distended, and the occurrence of acne rosacea may be observed as a 
consequence of circulatory disturbances. A varicose condition of the 
superficial veins may be developed with all the attendant evils of such 
a disorder. Actual extravasation of blood into the cutaneous tissues 
may occur either as a consequence of cutaneous embolisms, or by reason 
of the development of a genuine hemorrhagic tendency that reminds 
the observer of the phenomena of purpura hemorrhagica. 

(Edema is one of the most frequent and persistent consequences of 
valvular disease. In depends for its existence upon increasing blood 
pressure in the venous and lymphatic systems, and also upon alter- 
ations in the quality of the blood, and in the structure of the walls of 



ENDOCARDIAL DISEASES. 539 

the capillary vessels, which render them more permeable by the liquid 
portions of the blood. 

The occurrence of dropsy is first noticed, in the lower extremities, 
around the ankles, which swell during the daytime and subside at night 
while the patient is in bed. As the disease progresses, this condition be- 
comes constant and extends upward until it occupies the whole of the low- 
er extremities and invades the external sexual parts, and the subcutaneous 
tissues of the body, finally reaching the upper extremities and the face. 
Long duration of this condition is usually attended with thickening of 
the subcutaneous areolar tissue. The epithelial surface of the skin may 
also become thickened, inflamed, and blistered, after a fashion that is 
strongly suggestive of erysipelas. The skin may finally rupture, and 
an oozing of serum may thus become established. If life be sufficiently 
prolonged, ulceration and gangrene of the skin may also occur. 

The serous cavities of the body are in like manner invaded by the 
dropsical transudation. The peritoneal cavity is usually involved at an 
early period ; after that, the cavities within the thorax, and finally the 
spaces within the cranium, may become distended in like manner. It 
is evident that such accumulations of liquid cannot be formed without 
serious interference with the functions of adjacent organs that are thus 
subjected to an unusual degree of pressure. 

The cavities of the joints sometimes become distended and painful, 
even though every indication of rheumatism is absent. The tempera- 
ture of the body may remain normal, or it may sink below the natural 
level. Its elevation is usually caused by the intercurrence of embolic 
processes. The pulse is generally frequent, feeble, and weak or inter- 
mittent. Palpitation of the heart, which may be either genuine or only 
subjective in its character, is a very common occurrence. Uneasy sensa- 
tions in the cardiac region are not unfrequent. In many cases they 
are apparently due to irritation of the cardiac plexus through dilatation 
of the aorta. 

As a consequence of endocardial disease, thrombosis may occur within 
the cavities of the heart. Detached portions of such clots may be car- 
ried by the course of the circulation into distant organs, where they 
occasion embolic processes. Sometimes the extension of the endocardial 
clots into the branches of the pulmonary artery may produce an arrest 
of the circulation and sudden death. 

It occasionally happens that the excessively dilated or degenerated 
heart muscle ruptures and produces sudden death. 

In the majority of cases there is great complaint of want of air. 
This sometimes occurs periodically, sometimes in connection with car- 
diac palpitation or other excitement. It may be caused by mechanical 
pressure upon the lungs, through great enlargement of the heart, or by 
reason of the occurrence of hydrothorax or ascites. Over-distention 
of the stomach may produce a similar effect, but in many cases it seems 
to depend upon pulmonary disorders, such as hemorrhagic infarcts, or 
bronchial catarrh, or the direct compression of the left bronchus by an 
hypertrophied portion of the heart. As a consequence of these pul- 
monary disturbances, the patient may cough, and may expectorate 
blood for a considerable period of time, especially when pulmonary in- 



540 DISEASES 01 THE ORGANS OF CIRCULATION. 

farction has taken place. In certain cases the expectorated matter 
resembles the brownish sputum of pneumonia. Microscopical exami- 
nation of such sputa reveals the presence of large granular epithelial 
cells, with an abundance of pigment and crystals of hsematoidin, de- 
rived from the blood that has been extra vasated within the lungs. 

Death is not unfrequently caused by cedema of the lungs. Some- 
times it may be produced by oedema of the glottis. Inflammation of 
the lungs is a not uncommon occurrence. Epistaxis sometimes happens. 
Increase of pressure in the bloodvessels of the head is indicated by 
dizziness, humming in the ears, and flashes of light before the eyes. 
Opposite conditions of cerebral anosmia occasion persistent weakness 
and prostration. 

Loss of appetite and indigestion are very common as a consequence 
of catarrhal states of the digestive organs. Extravasation of blood into 
the mucous membrane of the mouth is sometimes observed as a conse- 
quence of dissolution of the blood. Attacks of cardialgia are sometimes 
referred to conditions of the stomach rather than to their actual source in 
the heart, especially when accompanied by obstinate vomiting that sug- 
gests ulceration of the stomach. The bowels are generally constipated, 
though occasionally there is diarrhoea. Haemorrhoids are frequently 
present, and intestinal hemorrhage sometimes occurs in consequence of 
their existence, or by reason of embolic processes in the mesenteric 
vessels. 

The liver is often considerably enlarged, producing a sensation of 
tension and weight, or even of pain in the right hypochondrium. The 
lower border of the organ can be felt distinctly below the ribs. In 
chronic cases the liver sometimes becomes reduced in size. 

The spleen is less frequently enlarged, since the portal circulation 
seems to shield that organ from the direct effects of retrograde blood 
pressure. 

As the compensatory vigor of the heart fails, the urine diminishes in 
quantity, deepens in color, and increases its specific gravity, frequently 
depositing an abundant sediment of urates when cooled. Hematuria 
does not often occur unless the kidneys become inflamed or involved 
in embolic processes. A catarrhal condition of the genito -urinary 
organs is occasionally observed. In the female sex, there is leucorrhoea 
and profuse menstruation ; in the male sex. varicocele and hydrocele 
are not uncommon. Embolic, hemorrhagic, and inflammatory pro- 
cesses are sometimes visible in the retina. 

In addition to the cerebral disturbances that have been mentioned, 
intra-cranial hemorrhage sometimes occurs, in consequence of arterio- 
sclerosis or fatty degeneration of the cerebral vessels. Epileptiform 
attacks may accompany such changes. 

The occurrence of valvular lesions within the heart in early life 
interferes with the groioth and healthy development of the patient ; such 
children are listless, timid, and slow to learn. In later life hypoclion- 
dria and melancholia sometimes develop, though a tendency to insanity 
is not remarkable among cardiac patients. 

The embolic processes that may originate in cardiac disease require 
special notice. "When they proceed from the right heart, the branches 



ENDOCARDIAL DISEASES. 541 

of the pulmonary artery are the seats of obstruction, and hemorrhagic 
infarctions are produced in the lungs. They may be recognized by 
their wedged-shaped form, the base of the pyramid being directed 
toward the periphery of the lung, and its apex toward the point of 
obstruction, where the embolus may be discovered on section of the 
arterial twig. The emboli that proceed from the left heart are most 
frequently discovered in the arteries of the extremities and in the 
splenic, renal, cerebral, gastro-intestinal, hepatic, and cutaneous arteries. 
The occurrence of such obstruction may be recognized by local pain, 
followed by elevation of the temperature, with chills, fever, and sweat- 
ing when the internal organs are involved, and followed by fall of tem- 
perature and disappearance of arterial pulsation beyond the point of 
obstruction when the circulation in the extremities is involved. The 
left lower limb is more frequently affected than the right, because of 
the greater directness of the passage of blood into the left bifurcation 
of the aorta. Sometimes the entire lower portion of the body and the 
lower limbs are deprived of blood through obstruction above the aortic 
bifurcation. In other cases simultaneous closure of both iliac arteries 
may occur. The temperature of the limbs falls rapidly. The toes 
grow dry and mummified, while the fleshy portions of the leg and thigh 
tend to fall into a condition of moist gangrene. Similar processes may 
be observed in the upper extremities. Embolism of the cerebral arte- 
ries occurs more frequently in the territory that receives its blood 
through the left carotid artery, because that vessel furnishes the most 
direct course from the heart to the brain. The left Sylvian artery is 
the favorite seat of embolism. Aphasia and hemiplegia may be thus 
produced. 

The formation of thrombi is observed sometimes in the large veins. 
Detached portions of these clots may find their way into the right heart, 
and thence into the branches of the pulmonary artery, producing sudden 
death. 

It is hardly necessary to allude to the increased dangers that attend 
intercurrent diseases when associated with valvular disease of the heart. 
The already overburdened organ must necessarily be found less capable 
of enduring the depressing influences of fever and the other incidents 
of acute disease. Especially is this the case when diseases of the organs 
of respiration or the processes connected with pregnancy and child- 
birth add to the difficulties that attend the circulation of the blood. 

The duration of valvular disease depends largely upon the nature 
of the lesion and the endurance of the patient ; occurring in early life, 
it greatly shortens the period of existence ; debilitated patients may 
finish their course in a few weeks or months. As a general rule, aortic 
defects are more consistent with length of life than other forms of 
valvular disease, for the reason that the superior muscular vigor of the 
left heart is favorable to the process of compensation. 

Diagnosis. The diagnosis of valvular lesions depends upon the 
physical signs previously enumerated. It will be useful to mention the 
particular difficulties that interfere with diagnosis. 

It is easier to recognize those defects that are accompanied by a 
diastolic murmur than those which produce a systolic murmur, for the 



542 DISEASES OF THE ORGANS OF CIRCULATION. 

reason that the first hardly ever have any other cause than the actual 
lesion, while murmurs of the second variety may originate in febrile or 
anaemic conditions of the patient. A systolic murmur can be ascribed 
to valvular lesions only when dilatation and hypertrophy of the corre- 
sponding portion of the heart are present. Hypertrophy of the right 
ventricle, it must be remembered, is accompanied by accentuation of 
the second sound at the entrance of the pulmonary artery, while hyper- 
trophy of the left ventricle is indicated by unusual strength of the pulse 
at the wrist. Accidental murmurs are generally unaccompanied by 
the occurrence of fremitus. It must not be forgotten that endocardial 
murmurs are sometimes absent during repose. The subject of examina- 
tion should therefore be made to execute active muscular movements, 
and should be examined in different positions, in order to arrive at a 
positive diagnosis. It is generally the case that an endocardial murmur 
belongs to the valve in connection with which it is most audible. The 
fact that the diastolic murmur which accompanies insufficiency of the 
aortic valve is generally louder over the middle of the sternum, must 
be explained by the fact that the murmur is not produced in the 
valvular opening, but within the ventricle where the vortical movements 
of the blood occur. For a similar reason the systolic murmur of mitral 
regurgitation is often loudest over the apparent entrance of the pul- 
monary artery. 

Other difficulties which may arise in connection with diagnosis must 
be overcome by a careful consideration of the various physical signs 
that have been enumerated on preceding pages. 

Prognosis. The prognosis in valvular disease is always unfavor- 
able. Disease of the aortic valve, for reasons already mentioned, is 
less dangerous than diseases of the other valves. The extension of 
disease to more than one valve increases the dangers to which the 
patient is liable. The occurrence of cardialgia, palpitation, irregularity 
of the cardiac movements, intermittence of the pulse, feeble contraction 
of the heart, with progressive diminution of its activity, are all indica- 
tions of failing energy and of increasing danger. 

Among external conditions that unfavorably affect the prognosis may 
be mentioned poverty, hunger, and the exigencies of a laborious life, 
though a constitutional weakness is also of unfavorable import. 

Treatment. Unfortunately there is no remedial agent that exerts 
any direct or perceptible influence upon the healing of valvular lesions 
of the heart. Iodide of potassium, mercury, chloride of ammonium, 
inhalations of the carbonate of sodium, and blisters over the cardiac 
region, have all been employed without appreciable result. The use of 
brine-baths is occasionally attended with favorable results, but disap- 
pointment is the rule. The principal indication for treatment is the 
preservation of the compensatory power of the heart. This must be 
effected by a wholesome diet, consisting principally of milk, eggs, 
broths, lean meat, stewed fruit, and such vegetables as the experience 
of the patient has recommended. Palpitation and difficult respiration 
may be somewhat relieved by the substitution of small and frequent 
repasts for the ordinary substantial daily meals. Strong tea and coffee 
and spirituous liquors should be forbidden, though it may be advisable in 



ENDOCARDIAL DISEASES. 543 

debilitated cases to make use of moderate quantities of wine and beer. 
Any considerable amount of liquid beyond the actual necessity of the 
patient should be avoided, because of the increased embarrassment of 
the heart that follows any increase in the amount of fluids that must 
circulate through that organ. All forms of violent exercise must be 
forbidden, also hot and cold baths should be discontinued, though cold 
sponging may be permitted. Gentle exercise in the open air is always 
desirable. The bowels should be moved every day ; if this cannot be 
accomplished by the use of fruits and vegetables as a part of the diet, 
the patient must have recourse to the aid of aloes and rhubarb (com- 
pound rhubarb pills). The bitter waters, such as Frederichshall or 
Hunyadi-Janos, are useful. 

During the cold months of the year the patient may seek a warm 
climate with advantage ; but it must not be forgotten that sea voyages 
and long journeys sometimes conduct enfeebled cases to a speedy ter- 
mination. 

When the signs of heart failure appear as a consequence of excessive 
dilatation or degeneration of the cardiac tissues, it becomes necessary 
to resort to the administration of remedial agents. Chief among these 
are the preparations of digitalis. These are especially useful in cases that 
are marked by feeble and irregular movement of the organ. The 
patient should be kept in bed, and an ice-bag may be laid over the 
heart, in order to retard its accelerated movements. A tablespoonful of 
the infusion of digitalis may be administered every two hours, and with 
this may be associated sufficient doses of bitartrate of potassium in con- 
stipated conditions of the bowels. If digitalis disturb the digestive 
organs, it will be found useful to add a small quantity of dilute alcohol 
to the infusion, or to substitute some other remedy in its place. This 
becomes absolutely necessary when the cumulative effects of the drug 
are developed, e. g., a slow and irregular pulse, cerebral confusion, 
flashes of light before the eyes, humming in the ears, vomiting, epi- 
gastric pain, diarrhoea, and general prostration. 

When a considerable degree of cyanosis marks the course of the dis- 
ease it becomes necessary to employ cardiac stimulants in association 
with digitalis. For this purpose, whiskey and water, valerian, and 
camphor, may be employed. A grain each of camphor, powdered 
digitalis, and capsicum, may be given in pill form every two or three 
hours. 

Sluggish kidneys may be stimulated advantageously by the admin- 
istration of citrate of potassium, in scruple doses, w 7 ith a tablespoonful 
of the infusion of digitalis, added to a half-tumblerful of water, every 
two hours. A powder containing two or three grains of calomel and a 
grain of powdered digitalis may be given three times a day during three 
successive days, for the same purpose. The mouth should be protected 
at the same time against salivation by frequent gargling with a five per 
cent, solution of the chlorate of potassium. 

As a substitute for digitalis, may be given the tincture of strophan- 
tus in ten-drop doses three times a day ; or the sulphate of sparteine 
(three grains three times a day) ; or hypodermic injections of the soluble 
salts of caffeine, preferably the sodio-benzoate or the sodio-salicylate of 



544 DISEASES OF THE ORGANS OF CIRCULATION. 

caffeine, -which may be employed in two-grain doses once or twice a 
day. Less reliable preparations are the infusion of Adonis yernalis. 
and the infusion, or the tincture, of convallaria majalis. 

Anaemic patients require the administration of iron, which may be 
given in the form of iron by hydrogen. Of this, three grains, with half 
a grain each of quinine and powdered digitalis, may be given in pill form 
four times a day. Mineral waters containing iron are useful in many 
cases. 

Pulmonary symptoms must be treated with expectorants, and with 
styptics if hemorrhage should occur. 

Cardiac palpitation and distress may require the hypodermic use of 
morphine. To this may be added a minute quantity of atropine if the 
patient be not over-sensitive to the disagreeable effects of that remedy. 
It is desirable to postpone this method of relief to the latest possible 
period consistent with the comfort of the patient. 

The development of dropsy may sometimes be hindered by a milk 
diet, especially if that article of food be relished by the patient. It 
should be boiled, and drank in small quantities frequently, and the 
daily amount may be increased until it reaches two or three quarts. 
In this way extensive cedema may be rapidly reduced in many cases. 
But when diuretics and drastic cathartics fail to reduce the dropsical 
accumulation, it is necessary to resort to the frequent use of hot air 
baths. The patient should lie in bed. wrapped in a woollen blanket. 
with the bed-clothing supported above his body by a light framework. 
A current of hot air may then be introduced under the clothing through 
the pipe of a tin stove containing a spirit-lamp at the foot of the bed. 
In this way perspiration may be excited and continued for an hour, or 
longer. Daily repetition of this process increases its efficiency. But 
when all other measures fail it becomes necessary to puncture the lower 
limbs of the patient. This may be effected either by simple puncture 
of the skin, with a sharp awl. at different points upon the swollen feet 
and legs, which should then be wrapped in soft cloths and covered with 
oiled cloth or rubber sheeting, to prevent saturation of surrounding 
objects. Still more effectual is the employment of Southey's trocar and 
canula, which may be introduced into the dropsical limbs with appro- 
priate antiseptic precautions. 



CONGENITAL VALVULAR LESIONS OF THE HEART. 

Congenital Cyanosis — Morbus Coeruleus. 

Etiology and Pathological Anatomy. Valvular defects within 

the heart may originate during fretal life. They occur most frequently 
upon the right side of the heart, which, before birth, receives oxy- 
genated blood from the placenta, and is more actively engaged than the 
left heart in the ante-natal circulation of the blood. Not only the 
valvular structures, but the cardiac walls and the fetal passages, such 



CONGENITAL VALVULAR LESIONS OF HEART. 545 

as the foramen ovale and the ductus arteriosus, may be involved. It 
was long believed that endocardial inflammation was the cause of the 
observed lesions, but there is a growing belief that these defects may 
have their origin not unfrequently in defective development of the car- 
diac structures. They are more frequently observed in male children 
than in female, and often their hereditary occurrence has been remarked. 

Symptoms and Diagnosis. The most conspicuous symptom of 
congenital endocardial defect is cyanosis, though cases have been 
described in which communications between the right heart and the 
left were discovered after death without the occurrence of cyanosis 
during life. The discoloration of the skin is usually increased by 
every agitation and exertion on the part of the patient. The symptom 
is exceedingly conspicuous at the moment of birth, and is usually 
followed by the speedy death of the infant. If life be prolonged, such 
children are liable to suffocative or convulsive attacks which sometimes 
terminate in death. The bodily development is usually retarded and 
deficient, the eyeballs are sometimes excessively prominent, the nose 
turned up, the lips and the finger-nails are blue, and the ends of the fin- 
gers and toes are club-shaped so that the hand assumes somewhat the 
appearance of a claw or talon. Along with other symptoms of 
defective nutrition the patients complain of chilliness, and their tem- 
perature is subnormal. A disposition to pulmonary consumption is 
not uncommon. 

The physical signs that are connected with the heart are, for the 
most part, identical with those which have been already enumerated in 
connection with valvular lesions of the heart. 

Prognosis. Death often occurs immediately after birth or in early 
life. It is an uncommon thing for a patient to live beyond the age of 
maturity. Death occurs as a consequence of pulmonary tuberculosis 
or other intercurrent diseases with symptoms of blood stasis. Life is 
sometimes terminated by convulsions. 

Treatment. The general rules for treatment that have been given 
on a preceding page must guide the care of these patients. Inhalation 
of oxygen and of compressed air has been recommended for the relief 
of cyanosis, but the good effects of such experiments must necessarily 
be transitory. 

Cardiac Thrombosis. 

Loose dark clots of blood of variable size can be found after death in 
the cavities of almost every heart, especially upon the right side of that 
organ. Sometimes they have become considerably discolored and 
fibrinous, presenting an elastic and semi-organized appearance. These 
masses form at the time of death, especially when the movements of the 
heart have been enfeebled or retarded for some time before the termi- 
nation of life. They must not be mistaken for true cardiac thrombi. 
These structures are closely adherent to the endocardial wall and 
require considerable force for their separation ; they are also of a much 
firmer consistency than that of the heart clots. Their color is of a 
brownish red or gray, and the older they are the more colorless they 
appear. They are most frequently observed in the auricular appendices 

35 



546 DISEASES OF THE ORGANS OF CIRCULATION. 

and near the apex of the heart, especially upon the right side of the 
organ In size they vary from the head of a pin to a hen's egg. They 
may occur singly or in considerable number. Sometimes the central 
portion becomes softened and occupied by a brownish red liquid resem- 
bling the contents of a cyst. Microscopical examination, however, 
excludes pus cells, and reveals only the presence of degenerate round 
cells with hsematoidin and granular detritus. Sometimes the mass 
becomes calcined. In certain cases a thrombus may protrude into 
other cavities besides those in which it had its origin, extending even 
into the aorta and its branches. It is obvious that embolic processes in 
distant parts of the body may have their origin in detached portions of 
a cardiac thrombus. 

Etiology. Without previous injury or disease of the endocardium 
a thrombus cannot be formed. The existence of the disease therefore 
implies the previous occurrence of retardation of the blood current and 
the incidence of other cardiac diseases by which the endocardial lining 
becomes detached at certain points. Where that has taken place the 
deposit of fibrin follows, and is attended with a low grade of organiza- 
tion by which the structure of the thrombus is built up. The same 
causes also which occasion the organization of thrombi in the peripheral 
veins may lead to their growth within the heart. 

Symptoms. In many cases there are no symptoms, and the disease 
is only discovered after death. In other cases the symptoms are those 
which characterize a debilitated condition of the heart, e. g., feeble 
impulse, imperfectly audible heart sounds, irregular cardiac movements, 
faintness, dizziness, flashes of light before the eyes, partial deafness, 
humming in the ears, formication, chilliness, pallor, lividity and cold- 
ness of the skin, with a feeling of dyspnoea that is not dependent upon 
pulmonary disease. In other cases the symptoms are those which 
indicate valvular defects, and they are produced by encroachment of the 
thrombotic mass upon an endocardial valve. In other cases the symp- 
toms depend upon embolic processes which have their origin in the 
detachment of particles from the thrombotic growth. 

Diagnosis. A positive diagnosis is impossible during life, though 
specialists have undertaken to formulate rules for the recognition of 
endocardial growths. Such efforts, however, exhibit a theoretical 
refinement that is quite beyond the possibilities of clinical observation. 

Treatment. No special rules can be laid down for the treatment 
of cardiac thrombus. Symptoms must be met as they occur. 



DISEASES OF MUSCULAR SUBSTANCE OF HEART. 547 



CHAPTEE II. 

DISEASES OF THE MUSCULAR SUBSTANCE OF THE HEART. 

Dilatation of the Heart — Dilatatio Cordis. 

Etiology. Dilatation of the heart may involve only a single one 
of its cavities or the entire organ. It is most conspicuous either in the 
auricles or in the right ventricle, on account of their inferior provision 
with muscular fibres. It may be produced mechanically, through an 
increase of blood pressure that is consequent upon obstruction to the 
circulation; or it may be the consequence of deficient nutrition; or it 
may result from both causes. The worst forms of mechanical dilatation 
usually occur as a consequence of valvular diseases of the heart, e. g., 
the dilatation of the left ventricle that follows insufficiency of the aortic 
valve ; or the dilatation of the right side of the heart and of the left 
auricle that occurs in cases of insufficiency of the mitral valve. Such 
dilatation is usually accompanied by hypertrophy of the affected por- 
tions of the organ, but when it occurs in feeble, sickly, or elderly 
patients, such compensatory hypertrophy may fail to be developed. 

Dilatation and hypertrophy that are caused by disease of a single 
cardiac valve, e.g., insufficiency of the aortic valve, may affect only 
one cavity of the heart, e.g., the left ventricle; but when several or all 
of the cardiac valves are diseased, the entire organ becomes enlarged, 
and, sometimes, reaches enormous dimensions, rivalling those of a bull's 
heart ; whence the epithet Cor bovinum applied to such examples of 
hypertrophy. 

It is obvious that every cause of persistent increase of blood pressure 
in the aorta or pulmonary artery, must occasion a mechanical dilatation 
and hypertrophy of the corresponding ventricle. The principal causes 
of increased pressure in the aortic circulation are aneurisms of the aorta, 
constriction of its trunk, arterio-sclerosis, contraction of the kidneys, 
and pregnancy. Increased blood pressure within the pulmonary artery 
occurs chiefly in chronic pulmonary or pleural diseases, and in caries 
of the spinal column. Nutritive dilatation of the heart is consequent 
upon changes in the substance of the cardiac muscle. These are some- 
times of a transitory character and admit of recovery. Such are the 
conditions that accompany fever, by which the right ventricle is tem- 
porarily dilated. Similar conditions are observed in connection with 
the infective diseases, even in the absence of fever, as a consequence of 
the activity of the specific poisons that are generated by microbic infec- 
tion. Similar dilatation also testifies to the defective nutrition that is 
caused by chlorosis, or by chronic diseases, disturbances of digestion, 
and repeated losses of blood. It may result also from the poisonous 
action of alkalies, or mineral acids ; and it has been observed to occur 
after long-continued excessive muscular exertion on the part of delicate 
and feeble individuals. 



548 



DISEASES OF THE ORGANS OF CIRCULATION. 



Dilatation of the heart may be produced by local causes that interfere 
ivith the nutrition of its muscular substance, such as fatty degeneration, 
and inflammation of the myocardium. Constriction of the coronary 
arteries and veins, and pericarditis, may lead to a similar condition. 

Pathological Anatomy. Uncomplicated dilatation of the heart is 
easily recognized by the enlargement of its cavities, and by the in- 
creased thinness of their walls. Dilatation of a single ventricle may 
produce such a change in the size and form of the heart that the other 
undilated portions may appear like mere appendages of the enlarged 
portion. When the entire organ is affected it loses its conical form 

Fig. 115. 




Area of normal percussion dulness of heart, liver, and spleen. (Slightly modified 

from Weil.) 



and assumes that of a rounded pouch. On opening the heart, its tis- 
sues appear relaxed, and the ventricular walls collapse upon themselves 
like fragments of wet chamois skin. In certain cases the muscular 
fibres of the auricles have been so widely stretched apart that the 
endocardium is almost in contact with the pericardium. The muscular 
substance of the organ is pale and sometimes friable; and its fibres 
may be fatty, waxy, or merely granular in structure, or they may 
exhibit no special degeneration. 



DISEASES OF MUSCULAR SUBSTANCE OF HEART. 549 

Postmortem dilatation of the heart may be distinguished from 
genuine cardiac dilatation by the presence of post-mortem discoloration 
of the endocardium through imbibition of hemoglobin, and by the fact 
that such dilatation generally occurs after death from chronic diseases 
of the respiratory organs, or from suffocation. In such cases the 
right side of the heart is over-distended with blood, and contracts 
quickly after its contents have been removed. 

Symptoms. The symptoms of cardiac dilatation are principally 
connected with the local physical signs of increase in the dimensions of 
the organ. (Fig. 115.) When the left ventricle alone is dilated, the area of 
dulness is extended downward as far as the sixth or seventh intercostal 

Fig. 116. 




Cardiac dulness increased from hypertrophy of both ventricles. (Finlayson.) 



space, outward, sometimes, beyond the left mammary line, and upward as 
far as the second rib, instead of being limited by the third rib. The apex 
beat may be felt over a wider space than common, and the force of its 
impulse is considerably diminished. The pulse at the wrist also ex- 
hibits a corresponding reduction of vigor. 

Dilatation of the right ventricle causes an extension of dulness be- 
yond the right border of the sternum, sometimes to a distance of an 
inch or more at the level of the fourth costal cartilage, especially if the 
right auricle, as well as the ventricle, be dilated. Dilatation of the 
entire heart produces an extension of cardiac dulness in all directions. 
(Fig. 116.) 



550 DISEASES OF THE ORGANS OF CIRCULATION. 

The cardiac sounds are considerably diminished, and are sometimes 
associated with systolic murmurs. The movements of the heart often 
exhibit uncommon rapidity that is sometimes connected with difficulty 
of breathing or with palpitation and pain. The veins are distended, 
while the arteries contain less than the normal amount of blood, condi- 
tions which tend to produce syncope by reason of cerebral anaemia. 

The duration of the disease depends upon the nature of its cause ; 
the dilatation that is associated with febrile states of the system re- 
covers rapidly and completely, sometimes within a few hours. But if 
the changes in the muscular substance of the heart are permanent, the 
phenomena of circulatory obstruction soon appear; the jugular veins 
dilate and often pulsate ; cyanosis appears ; and, presently, more serious 
phenomena are developed, e. g., oedema, reduction in the amount of the 
urine, albuminuria, enlargement of the liver, bronchial catarrh, haemop- 
tysis, and death. 

Diagnosis. Dilatation of the heart must be distinguished from 
pericarditis by the absence of friction sounds, and by the peculiar 
figure of the area of dulness, as well as by the characteristic impulse 
that accompanies the apex beat. The change in the extension of 
cardiac dulness that is produced by changes in the position of the body 
when pericarditis exists, is hardly ever observed in dilatation of the 
heart. It is distinguished from dulness that is produced by exudation 
into the anterior border of the lungs, or from encysted pleurisy in the 
vicinity of the heart, by the signs that will be described in connection 
with the diagnosis of pericardititis. The presence of thoracic aneurisms 
or tumors may render it difficult to define accurately the limits of 
cardiac enlargement. Finally, dilatation may be concealed by pul- 
monary alhesions, or by an emphysematous condition of the lungs, 
which prevent the heart from crowding those organs aside as it becomes 
enlarged. 

Prognosis. The prognosis depends upon the cause of dilatation, 
and is most serious when degenerative changes in the muscular struc- 
ture of the heart have occurred. 

Treatment. The treatment of cardiac dilatation must conform to 
the underlying causes of the disease. Chlorosis and general enfeeble- 
ment of the body require the administration of iron, tonics, and a 
nutritious diet, in which milk should occupy the most important place. 
Febrile conditions require the ordinary treatment with cold baths and 
the administration of febrifuge remedies, in order to reduce the tem- 
perature by which the integrity of the cardiac tissues is threatened. 
Frequent pulsations of the heart should be reduced by the application 
of ice-bags over the cardiac region, and by the cautious use of digitalis 
or its substitutes. In all cases, rest, and the avoidance of excessive 
muscular exertion, must be enjoined. 

Hypertrophy of the Heart — Hypertrophia Cordis. 

Pathological Anatomy. Hypertrophy of the heart consists in an 
increase of the muscular tissue of the organ. This may be produced either 
by an enlargement of the individual muscular fibres or by increase of their 



DISEASES OF MUSCULAR SUBSTANCE OF HEART. 551 

number. Both conditions may be associated. The principal sign of 
hypertrophy of the heart is presented by an extraordinary thickening 
of its walls. This is almost invariably accompanied by a dilatation 
of the cavities with great enlargement of the entire organ, constituting 
what is termed excentric hypertrophy of the hea7*t. 

It occasionally happens that hypertrophy of the cardiac muscle exists 
without enlargement of the enclosed cavities, and they may seem to be 
even actually diminished in size. This is termed concentric hyper- 
trophy of the heart, and by some authors is thought to be a consequence 
of sudden development of rigor mortis during systolic contraction of the 
hypertrophied heart. This condition must be at all events distinguished 
from the contracted condition of the heart that is observed after death 
from sudden evacuation of the liquids of the body, such as occurs during 
cholera, or in the beheading of a criminal. 

The term simple hypertrophy is applied to cases that are marked by 
hypertrophy without concomitant dilatation of the heart spaces. 

Hypertrophy of the heart produces an unusual firmness and solidity 
of its structure. The muscular substance often exhibits no change in 
color, but sometimes it is unusually dark and pigmented. Sometimes 
isolated muscular fibres, or groups of fibres, exhibit evidence of fatty 
degeneration. This condition indicates the existence of incipient car- 
diac failure. 

The process of hypertrophy does not always involve the entire heart ; 
it may be either total, partial, or circumscribed. Partial hypertrophy 
involves only a single division of the organ ; circumscribed hypertrophy 
may be restricted to a single papillary muscle, or to the ventricular 
septum, or to the auricular appendices, or the conus arteriosus. The 
left ventricle is the common seat of hypertrophy ; the right side of the 
heart is more liable to dilatation without hypertrophy by reason of its 
muscular inferiority. 

The increase of space that is occupied by the heart within the thorax 
has been already sufficiently indicated in the description of cardiac 
dilatation. 

Etiology. Hypertrophy of the heart occurs when the organ per- 
forms an extraordinary amount of labor without diminution of its 
nutritive supply. In the majority of cases the increase of cardiac function 
is occasioned by obstruction of the circulation of the blood. This may 
be caused, so far as the left ventricle is concerned, either by disease of 
the aortic valve, or by constriction of the aorta, which may result from 
congenital causes ; or from insufficiency of the mitral valve ; or from 
the pressure exercised by neighboring tumors ; or by aneurismal or 
other dilatation of the aorta or its principal branches ; or by diseases of 
the vascular walls which interfere with their elasticity. It may also be 
the result of pregnancy, though some authors have endeavored to show 
that the apparent enlargement of the organ during the reproductive 
effort, is caused by upward pressure of the diaphragm that crowds the 
heart out of its normal position, and produces a fictitious semblance of 
hypertrophy. 

Hypertrophy of the left ventricle is observed frequently in contracted 
states of the kidney. It may also occur in acute or chronic nephritis, 



552 DISEASES OF THE ORGANS OF CIRCULATION. 

or in connection with renal calculi and hydronephrosis, probably be- 
cause the blood becomes overcharged with excrementitious substances 
that excite the hypertrophic process in the muscular structure of the 
heart. 

Hypertrophy of the right ventricle may be occasioned by anything 
that hinders the passage of blood from the right ventricle through the 
lungs, e. g., diseases of the pulmonary valve; constrictions of the 
pulmonary artery by reason of tumors, aneurisms, or arterio-sclerosis ; 
chronic diseases of the pleura or of the lungs, which produce compres- 
sion or obliteration of the pulmonary capillaries. Cardiac hypertrophy 
rarely occurs during the course of pulmonary tuberculosis, because the 
degree of cachexia is so great as to interfere with the nutrition of the 
muscular substance of the heart. 

An enlargement of the entire heart is observed when the causes that 
produce hypertrophy of its different portions are simultaneously asso- 
ciated. This is frequently observed in valvular disease, and it may 
be produced by pericarditis and by myocarditis. It sometimes occurs as 
a consequence of excessively frequent movements of the heart, such as 
are exhibited by nervous persons who suffer with palpitation, followed by 
gradual enlargement of the heart. A similar change often accompanies 
exophthalmic goitre. It is not uncommon among plethoric persons who 
indulge in excessive eating and drinking. It may in like manner be 
produced by toxemic conditions connected with the abuse of tea, coffee, 
tobacco and alcohol, or the introduction of lead into the circulation. 

Besides the cases just mentioned there are many for which no 
apparent cause can be discovered. These are termed cases of primary 
or idiopathic hypertrophy of the heart. They are generally dependent 
upon long-continued and excessive muscular exertion, and are en- 
countered chiefly among the laboring classes. 

Symptoms. The symptoms which are connected with the exciting 
causes of cardiac hypertrophy must be distinguished from the physical 
signs that are produced by the enlargement of the organ. The 
diagnosis depends upon the physical signs of enlargement of the entire 
organ, or such portions as may have undergone change in partial 
hypertrophy. In hypertrophy of the left ventricle, the precordial 
region is considerably prominent, especially in the case of women or 
children whose ribs are yielding. The apex beat is extraordinarily 
vigorous, and the pulsatory impulse is not limited to the point 
of contact with the thoracic wall, but is diffused over the greater 
portion of the left side of the chest; in some cases the whole 
body and the bed upon which the patient lies participate in the systolic 
impulse. The apex beat is most distinctly seen and felt to the left and 
downward. Sometimes a short, diastolic, aortic impulse is felt in the 
second intercostal space upon the right side of the sternum, alternately 
with the systolic apex beat. Auscultation indicates a state of increased 
tension in the aortic valve during diastole, producing an accentuation 
of the second sound oyer that valve. The carotid arteries and their 
branches beat with increased force, which sometimes produces a sys- 
tolic murmur that is audible over their course as a consequence of 



DISEASES OF MUSCULAR SUBSTANCE OF HEART. 553 

excessive tension and vibration of the arterial walls. The pulse at the 
wrist exhibits increased force and tension. 

Subjective symptoms may be either entirely absent, or may be limited 
to the occasion of excessive muscular exertion, when palpitation and 
shortness of breath are not uncommon. Sometimes a feeling of con- 
striction or pressure is manifested in the cardiac region, and may be 
accompanied by pain extending into the left arm. Usually it becomes 
difficult or impossible to lie upon the left side ; sometimes there are 
evidences of cerebral congestion, e. g., dizziness, pressure in the head, 
flashes of light before the eyes, humming sounds in the ears, or a sub- 
jective sensation of audible pulsation in the head. Epistaxis is not 
uncommon, and if the cerebral vessels are diseased hemorrhage may 
occur within the cranium. Female patients sometimes suffer with pro- 
fuse menstruation. 

Hypertrophy of the right ventricle is indicated by the diffusion of 
cardiac impulse toward the right, where it becomes visible over the 
lower portion of the sternum. Auscultation indicates the usual increase 
of diastolic sound at the entrance of the pulmonary artery. 

Hypertrophy of the right side of the heart is liable to association 
with cyanosis, shortness of breath, and bronchial catarrh, or even 
hemorrhages of the air passages. Hypertrophy of the entire heart is 
indicated by the coexistence of the symptoms and signs that indicate 
enlargement of the different portions of the organ. 

So long as the muscular substance of the heart preserves its nutritive 
integrity the patient may enjoy a considerable degree of health, but 
when nutrition fails and muscular degeneration begins, the symptoms 
of circulatory obstruction appear, and life is terminated after a period 
of greater or less duration, characterized by the occurrence of dyspnoea, 
palpitation, irregular and frequently rapid pulse, oedema, diminution of 
urine, sometimes associated with albuminuria, enlargement of the liver, 
dropsy, cough, haemoptysis, and asphyxia. Sometimes death is pre- 
ceded by cerebral symptoms terminating in coma and convulsions. 

Treatment. Since hypertrophy of the heart is the natural means 
by which compensation for circulatory obstruction is effected, the treat- 
ment must have for its object the accomplishment of hypertrophy and 
the prevention of degeneration in the muscular tissue of the heart. 
This cannot be accomplished by the administration of drugs, but a favor- 
able result must be reached through the employment of proper dietetic 
and hygienic measures. Violent exercise and cold baths must be for- 
bidden, though cold sponging, night and morning, has a favorable 
effect. Coffee, tea, and tobacco must be forbidden on account of their 
irritating effects upon the heart. The diet must consist of easily 
digested substances such as milk, eggs, broths, lean and tender meat, 
with stewed fruit and such vegetables as do not cause indigestion with 
the development of gas in the stomach and intestines by which the 
diaphragm may be crowded against the heart. Fats and starches 
should be avoided. Beer and light wines may be recommended in 
moderation in cases that are characterized by imperfect nutrition, but 
they must be refused to plethoric patients, for whom may be prescribed 
with advantage a milk cure or grape cure. Constipated conditions of 



::- !■ : s z a s - s : _- _ ^ ^ : .-. 3- ^ > s :• _- ::?.:. la.:o\. 

the bowels must be prevented: palpitation may be obviated by the 
recumbent position and by the application of an ice-: _ the 

heart. Counter-irritation produces little or no effect. Symptoms of 
: ilui t ::J1 for the cautious use of digitalis or its substi: 

Atrophy of the Heart — Atrophia Cordis. 

' i of the "heart has been >bserved is i consequence ::' -enile 
changes, or cachectic conditions, or as a result of pressure exerted by 
stinal tumors, or chronic pericardial exudations. ; :: restrictions 
of the coronary arteries. It is ■ condition that can seal t admit of 
recc gnition with certainty before death, nor does it require any special 
treatment >esides -^hat is indicated by existing states :: general pros- 
tration and debility. 

Fatty Heart — Cor Adiposum. 

Pathological A>~ai:vt. This disease consists in an excessive 
se : the : : naturally exists about the base of the heart 

and the large vessels. It sometimes envelops the entire organ with an 
adipose mantle nearly an inch in thickness. It : ccasionally invades 
the connective tissue beneath the epicardium. and separates the muscular 
fibres in the ventricular walls. In addition to this, the indiv 

•es may undergo fatty degeneration, by which the mus- 
cular substance of the heart is still farther weakened. The coronary 
arteries and the aorta also may sometimes exhibit e : Lenee :f endar- 
teritis 

Etioia "?t. Iii the majority of esses, fatty heart is the local exhi- 
bition of a general tendency to obesity which is exhibited by intemperate 
persons and high livers who consume too great a quantity of starchy 
saccharine food. Hereditary predisposition sometimes exists. 
is more commonly observed among men than among women, 
cially after the fortieth year has been passed. Among women it is 
sometimes observed, apparently as a consequence of amenorrhoea and 
sterility, or after childbirth and the turn of life. 

The fatty hei - ia occurs as a consequence of a reduction in 

the oxygen-carrying power of the blood, such as is Aeerved after 
hemorrhages, and during conditions of cachexia that accompany chloro- 
: ; .. scrofula* Addison - : . 

Symptoms. It often happens that th< ;ce of superfluous 

about the heart is only ed after death. In other cases a sn 

death without previous notable symptoms first ts ::ention to the 

condition of the individual. Id still other sases, the symptoms are 

that characterize an enfeebled condition of the heart, by r 
of which the circulation of blood is imperfectly performed. But, as 
none of these symptom- ssess a diagnostic character, il _ rally 
asary to consider the history of the patient with reference to 
tt the table The :e of obesity is also favorable to the 
gnosis of a fatty heart. The occurrence of an areus indi- 
cating a fatty degeneration along the border of the 



DISEASES OF MUSCULAR SUBSTANCE OF HEART. 555 

some degree of significance, though it is a not uncommon occurrence 
among elderly people who do not accumulate fat in the subcutaneous 
connective tissue. 

Enfeeblement of the heart is sometimes suddenly manifested after 
violent exertion of any kind, and becomes more and more developed 
with the progress of the disease. Its principal signs are excessive 
distention of the veins and a scanty flow of blood through the arteries. 
The cardiac impulse appears weakened, or even absent. Percussion 
generally indicates an extension of cardiac dulness. The heart sounds 
lose their force, and a systolic murmur frequently accompanies the first 
ventricular sound. In many cases the rhythm of the cardiac sounds is 
•disturbed by the substitution of a succession of beats with uniform in- 
tervals, like the galloping of a horse (bruit de galop — Galopprhythmus). 
The pulse at the wrist is small, weak, and often irregular. The periph- 
eral arteries are frequently calcified or sclerosed. 

Palpitation is not uncommon, either with or without previous physi- 
cal or mental excitement. It is sometimes accompanied by pain about 
the heart and extending into the left shoulder and arm. Sometimes 
these cases exhibit great difficulty of respiration, with copious perspira- 
tion and fall of temperature, forming a picture very similar to that of 
asthma. Hence the term cardiac asthma, that has been connected 
with them. 

Prominent among the symptoms of fatty heart have been described 
a great retardation of the pulse, pseudo-apoplectic seizures, and Cheyne- 
Stokes' respiration. The reduction of the pulse sometimes falls as low 
as eight or ten beats during a minute. It is the consequence of cere- 
bral anaemia and irritation of the inhibitory centre in the medulla 
oblongata. 

Pseudo-apoplectic attacks exhibit a superficial resemblance to 
genuine paralytic strokes ; but the patients recover rapidly, sometimes 
in the course of a few minutes, and paralytic symptoms are either 
absent or continue for a few hours only. These attacks are sometimes 
renewed many times in the course of a day, or they may occur at inter- 
vals during many weeks or months. Their incidence is frequently 
without warning, though patients sometimes feel a premonition of their 
approach. They are principally dependent upon a condition of cere- 
bral anaemia, and frequently may be averted by lowering the head 
below the level of the body. They are generally associated with 
changes in the beat of the pulse and disturbances of the respiration, 
and are sometimes accompanied by spasmodic contractions of the 
muscles in the limbs. 

Qheyne- Stokes respiration consists in a series of twenty or thirty 
respirations, at first shallow, then becoming deeper and deeper, and 
assuming the characteristics of asphyxia, followed by a pause of one- 
half or three-quarters of a minute, during which respiration is entirely 
suspended, after which the cycle is again renewed. (Fig. 117.) Slight 
local spasms sometimes appear toward the close of the respiratory 
pause; this symptom is frequently observed in connection with the 
apoplectiform attacks, and is especially common after the use of 



556 DISEASES OF THE ORGANS OF CIRCULATION. 

opiates. Its frequent concurrence with other diseases that affect the 
brain deprives it of any special diagnostic value. 

The duration of the disease may reach many years ; but the 
termination is frequently sudden and unexpected, as a consequence of 

Fig. 117. 



H 



1 



a 



►3 



m 






1 2 3 4 

Cheyne-Stokes' respiration. 1. Ascending series. 2. Descending series. 3. Period of 
apnoea, with one abortive respiration. 4. Period of apnrea disturbed by urging the patient 
to make voluntary respirations. (Finlaysojj.) 



DISEASES OF MUSCULAR SUBSTANCE OF HEART 557 

cardiac paralysis that is dependent upon over- exertion, such as may 
be witnessed in childbirth. Cerebral hemorrhage, apoplectiform at- 
tacks, oedema of the lungs, and embolism of the pulmonary arteries 
with hemorrhagic infarction, are among the causes of death. In a 
large proportion of cases death results from degeneration of the cardiac 
muscles, leading to delay in the circulation of the blood, with its usual 
consequences, dropsy, enlargement of the liver, diminution of the 
urine, albuminuria, bronchial catarrh, hemorrhagic infarcts, inflamma- 
tion or oedema of the lungs, convulsions, and coma. 

Diagnosis. It is not often that the diagnosis of fatty heart can 
attain to anything more than probability, since none of the symptoms 
which have been enumerated possess an absolutely diagnostic character. 
The history of the case, and the existence of obesity, in connection 
with such symptoms, will justify an inferential diagnosis of the con- 
dition of the heart. The prognosis is exceedingly variable. 

Treatment. Before the formulation of a system of treatment it is 
necessary to distinguish between cases of plethoric constitution and 
those which are characterized by anaemia. Patients belonging to the 
first class must reform their habits of life, abstaining from alcoholic 
excesses, and from indulgence in food that abounds in fat, sugar, and 
starch. Moderate exercise and massage must be employed for the 
purpose of invigorating the muscular structure of the heart. Iodide of 
potassium, in doses of from five to ten grains three times a day, has 
been recommended, as well as the use of gentle laxatives and diuretic 
mineral waters. 

Anaemic patients require a nutritious diet with a moderate quantity 
of fluids, and the use of wine and beer in quantity sufficient to aid 
nutrition. Massage, and exercise in the open air, must be cautiously 
undertaken, and must be increased as strength returns. Preparations 
of iron, and tonics, with mineral waters that contain iron, will be found 
useful. 

When the evidences of cardiac debility are apparent all patients 
must resort to the use of digitalis, as previously ordered. In severe 
cases, diuretics (^. Scillae acet., Sj; potass, carbonat., q. s. ad perf. 
saturationem;aq. petroselini §v; syr. scillae 5j. M. S. — A tablespoon- 
ful in water every two hours), or purgatives (sodii. sulph. Sj ; infus. 
sennae co., Sviij. M. S. — A tablespoonful several times a day) will 
be required. 

Symptoms of cerebral anaemia require the recumbent position, with 
the head low, and the use of cardiac and cerebral stimulants. Asth- 
matic paroxysms are often quickly relieved by the horizontal posi- 
tion, and by the use of ice externally and over the cardiac region. 
Strong coffee, and the tincture of strophantus (ten drops three times a 
day) or the sulphate of sparteine (one and a half grains three times a 
day) have been recommended. Narcotics should be used with great 
caution. Convalescence may be assisted by the long-continued 
administration of digitalis in small doses (Ify. Fol. digital, pulv. 5ss ; 
fcrri lactat., potass. nitrat.,aa 3\jss; ext.rhei,gr. x; pulv. altheae, q.s. ut 
f. pil. no. c. S. — Two pills after each meal-time. 



558 DISEASES OF THE ORGANS OF CIRCULATION. 



Acute Inflammation of the Heart — Myocarditis Acuta. 

Acute diffuse inflammation oftht cardiac parenchyma is character- 
ized by granular degeneration of the swollen muscular fibres, with 
increase in the number of their nuclei. In severe cases the process re- 
sults in fatty degeneration of the muscular fibres. These processes 
generally have their origin in the toxemic conditions that accompany 
infective diseases. 

Acute diffuse interstitial myocarditis depends in like manner upon 
constitutional infection involving the connective tissue of the cardiac 
muscle, which becomes infiltrated with round cells. 

Acute circumscribed myocarditis is usually the result of infective 
embolic processes in the branches of the coronary arteries, by which 
are produced numerous abscesses in the substance of the myocardium. 
It is. like other forms of myocarditis, the result of infective diseases, 
and of ulcerative endocarditis. The number and size of the abscesses 
mav be very considerable. Large abscesses, containing sometimes 
nearly an ounce of pus. may interfere considerably with the function of 
the heart. The purulent contents of a myocardial abscess may become 
encysted, or caseous, and. finally, calcified. Rupture of the abscess 
into the pericardium, or into one of the cavities of the heart, may take 
place. The pus that finds its way into the current of the blood trav- 
erses the entire arterial system, and may excite embolic processes of 
an infective character in any part of the body. By the pressure of 
blood into the cavity of such an abscess, when it communicates with an 
endocardial cavity, the external wall of the abscess will be subjected to 
pressure, with the formation of an acute cardiac aneurism as its result, 
^uch aneurisms expose the patient to great danger through their rapid 
growth and sudden rupture. Abscesses that are formed in the neigh- 
borhood of the auriculo-ventricular valve may produce insufficiency of 
those valves as a result of the processes that accompany their formation. 
Sometimes an abscess may burrow through the septum between the ven- 
tricles, opening a communication between different cavities upon oppo- 
site sides of the heart, with consequent disturbances of the circulation 
of the blood. 

Chronic Inflammation of the Heart — Myocarditis Chronica. 

Pathological Anatomy. — Chronic myocarditis consists in the 
gradual development of inflammatory induration in the connective 
tissue of the heart. The callosities which are thus produced appear in 
the form of gray patches, or streaks, imbedded among the muscular 
fibres ; and. sometimes, associated with them are fibres of the muscular 
tissue that have undergone fatty degeneration. These spots of indu- 
rated tissue may be exceedingly minute, or they may form hard and 
gristly masses, one or two inches in diameter. They are found, most 
frequently, in the wall of the left ventricle, near the apex, or in the 
septum between the ventricles. When formed during foetal life, they 
occur usually in the right ventricle. 

Chronic myocarditis is usually associated with chronic endocardial 



DISEASES OF MUSCULAR SUBSTANCE OF HEART. 559 

inflammation and with hypertrophy of such portions of the cardiac 
muscle as have escaped degeneration. The intima of the coronary 
arteries may undergo chronic inflammation, with consequent thrombosis 
and the production of infarcts in the muscular substance. If the papil- 
lary muscles become indurated, their function is unfavorably affected, 
and the phenomena of valvular insufficiency will appear. Indura- 
tion of the connective tissue in the conus arteriosus of either ventricle, 
produces constriction and the occurrence of many of the symptoms of 
stenosis of the arterial valves of the heart. Sometimes an indurated 
spot in the ventricular wall gradually yields to endocardial pressure, 
with the consequent development of a cardiac aneurism. In the 
majority of cases these aneurismal tumors spring from the left ventricle, 
near its apex. They have been known to reach the size of a man's 
head, forming a tumor that fills the whole left side of the thorax. 

Etiology. Chronic myocarditis may be produced by exposure to 
cold, by injuries of the thorax, by violent exertion, by excesses in the 
use of alcohol or tobacco, by lead poisoning, by infection with the 
causes of acute rheumatism, malaria, and syphilis. It may result from 
gout and diabetes ; and is often associated with diseases of the coronary 
arteries, and with chronic nephritis, especially with the contracting 
form of that inflammation. Inflammation of the endocardium, or of the 
pericardium, may lead to myocarditis through the extension of the 
inflammatory process to the tissues of the myocardium. The disease is 
more common among men than among women, and is especially fre- 
quent after middle life. 

Symptoms. Slight forms of myocarditis produce no perceptible 
consequences. Severe cases present symptoms that are sufficiently 
evident, though destitute of diagnostic value. Progressive diminution 
of cardiac power is one of the most specific symptoms. There is com- 
plaint of palpitation and shortness of breath after slight exertion ; 
sometimes associated with pain in the cardiac region and in the left 
arm, or extending into the epigastrium and abdominal cavity. Cardiac 
impulses and sounds are exceedingly weak, and the first ventricular 
sound is sometimes replaced by a systolic murmur. The bruit de galop 
is sometimes audible, the pulse is often intermittent, and, sometimes, 
very much retarded. Swelling of the cervical veins, cyanosis, catarrh 
of the respiratory passages, and disorders of digestion very frequently 
occur. The symptoms of circulatory obstruction finally appear, with a 
fatal result. Death sometimes occurs very suddenly. 

Prognosis. The prognosis of chronic myocarditis is always very 
grave. The most favorable cases are those which have been originated 
by syphilis, since they may yield to specific treatment. 

Treatment. Perfect rest of mind and body, with proper diet, are 
of the utmost importance. Rapid and irregular movements of the 
heart may be controlled by ice-bags upon the chest ; the appearance of 
symptoms that indicate cardiac failure is the signal for the employment 
of digitalis or its substitutes. Syphilitic cases may be treated with 
daily inunctions of mercurial ointment during the period of a month. 
Iodide of potassium in doses of five to ten grains three times a day, or 



560 DISEASES OF THE ORGANS OF CIRCULATION. 

a pill containing one-fourth of a grain of the proto-iodide of mercury 
three times a day. will be found useful. 

Rupture of the Heart — Cardiorrhexis Spontanea. 

ETIOLOGY. Spontaneous rupture of the heart only occurs as a con- 
sequence of previous degeneration of its muscular structure. This 
most frequently depends upon diseases of the coronary arteries which 
may lead to embolic or thrombotic processes, or may be associated with 
abscesses and softening of the heart. Chronic myocarditis, fatty heart, 
cardiac tumors, the development of parasites in the cardiac substance, 
and diseases of the cardiac valves, may all be followed by degeneration 
and rupture of the organ. 

Rupture of the heart is a disease of old age, usually occurring after 
the sixtieth year of life ; and is more frequent among males than among 
females. It is occasioned, generally, by some form of violent muscular 
action, though it may occur during sleep, or in conditions of perfect 
repose. 

Pathological Anatomy. Rupture of the heart may be total when 
it produces a solution of continuity in the entire thickness of the cardiac 
wall. It is partial when it involves only a few muscular fibres, or the 
papillary muscles, or trabecular of the ventricles, by which the attach- 
ments of the chordae tendinea? are released and the phenomena of 
valvular insufficiency are produced. 

Total rupture of the heart usually occurs through the wall of the left 
ventricle, near the apex ; next in frequency is the rupture of the right 
ventricle ; then, through the right auricle : and. rarest of all. through 
the left auricle. The rent is generally irregular and parallel with the 
course of the muscular fibres, which are partly torn and partly separated 
from one another. After death the fissure is found to be occupied with 
clotted blood, which also occupies the pericardial cavity, sometimes in 
great quantity. When adhesive pericarditis has previously obliterated 
the pericardial space the blood may find its way into the pleural cavity 
or along the trunks of the large arteries. 

Symptoms. Sudden death is the frequent consequence of rupture of 
the heart, but sometimes the symptoms are prolonged for a number of 
hours. There may be complaint of agonizing pain in the heart, the 
face grows pale, and the temperature of the body falls. The puis, 
comes rapid and almost imperceptible. The skin is covered with cold 
and clammy sweat : complete collapse occurs, and death follows. Some- 
times vomiting and purging, like that of cholera, are experienced This 
may be the result of cerebral anaemia, with consequent irritation of the 
- of the vagus nerve, or it may be the result of direct irritation of 
liac branches. The usual phenomena of syncope, sometimes 
culminating in convulsions and death, may also occur as a result of 
cerebral anaemia The physical signs of cardiac failure — weakness 
suppression of sounds and impulse — are present. Excessive effus: 

I into the pericardium will cause an extension of the area of cardiac 
dulness. 

The immediate \us( f leath is connected either with cardiac 



DISEASES OF MUSCULAK SUBSTANCE OF HEART. 561 

paralysis, or with cerebral anaemia, or as a direct consequence of 
shock. 

Diagnosis. Obviously the diagnosis of rupture can be only of 
an inferential character. Tolerable certainty is acquired when increas- 
ing heart failure is associated with the symptoms of internal hemor- 
rhage and rapid extension of the area of cardiac dulness. 

Treatment. Prophylactic treatment consists in the avoidance of 
every cause of excitement and over-exertion. If rupture of the heart 
be suspected the patient must be placed in the horizontal position, and 
a hypodermic injection of fifteen drops of ergotine, diluted with an 
equal quantity of water, may be made into the thoracic wall near the 
heart. Cardiac stimulants, e. g., wine, ether, camphor, musk, may be 
administered. If life be prolonged, digitalis, in tablespoonful doses of 
the infusion, may be administered every two hours, for the purpose 
of invigorating and regulating the action of the heart. 

Tumors of the Heart — Neoplasmata Cordis. 

Tumors involving the muscular structure of the heart seldom exist. 
Unless they acquire considerable dimensions they cannot be recognized, 
but sometimes they may interfere with the nutrition of the muscular 
fibres to an extent that weakens the organ, or they may obstruct the 
action of the cardiac valves, with production of corresponding symp- 
toms. Detachment of portions of their substance may excite embolic 
processes in remote parts of the body. Sudden death may thus be 
caused by obstruction of the aorta or pulmonary artery. 

Parasites. 

Cysticercus cellulosse, Pentastomum denticulatum, and Echinococcus 
sometimes invade the muscular substance of the heart. Only Echino- 
coccus cysts produce any serious disturbance. They are associated 
with the existence of similar parasitic structures in other organs. They 
may be as small as the head of a pin, or they may reach the size of an 
orange, and their number is sometimes very considerable. Their effects 
are produced by mechanical interference with the functions of the heart 
or by the detachment of embolic cysts by which distant arteries are 
obstructed. 

Misplacement of the Heart — Dislocatio Cordis. 

Among the ante-natal defects that sometimes attend foetal develop- 
ment may be mentioned misplacement of the heart into the right side 
of the thorax ; sometimes associated with universal transposition of the 
thoracic and abdominal organs. In other cases the heart retains its 
foetal position in the median line. These congenital defects are very 
apt to be associated with disposition to valvular disease. Sometimes 
there is partial or total absence of the sternum, so that the heart can 
be felt as a pulsating tumor immediately beneath the skin, a condition 
that is not incompatible with long life. In other cases the skin also is 
deficient, so that the heart lies completely exposed to view. This con- 

36 



562 DISEASES OF THE ORGANS OF CIRCULATION. 

dition constitutes what is termed ectopia cordis. Sometimes the heart 
is discovered within the abdominal cavity, and it has been known to 
occupy the cavity of an umbilical hernia. In other cases, it has been 
displaced, in the course of development, in an upward direction, so as 
to occupy a position in the upper part of the thorax, or even in the 7iecJc. 
Like the kidney, the heart sometimes exhibits such laxity in its con- 
nection with adjacent organs and structures that it may be described as 
& floating heart, a condition of things which generally occurs in cases 
of obesity after the removal of fat from the vicinity of the heart by 
excessive therapeutic activity which has deprived the organ of its pre- 
vious supports. 

Diseases of the Coronary Arteries. 

Experimental investigation has shown that ligature or obstruction of 
the coronary arteries upon the loiver animals produces irregularity or 
complete arrest of the movements of the heart. In this way may be 
explained cases of sudden death, which, on post-mortem examination, 
exhibit nothing but an atheromatous and constricted condition of the 
coronary arteries. Insufficiency of cardiac vigor, asthmatic difficulty 
of respiration, and obstruction of the circulation, are not uncommon 
consequences of arteriosclerosis affecting the coronary arteries. 
Hemorrhagic infarcts, muscular degeneration, and rupture of the heart, 
sometimes follow upon coronary disease. Myocarditis with induration 
of the connective tissue of the organ, and the production of various 
modifications in the walls of the heart or in its valves, may all be asso- 
ciated with these changes, which, moreover, may also involve the aorta 
and its branches, even as far as the kidneys. Coronary disease is 
associated with the degenerative processes of old age. It is more com- 
mon among males than among females, and is often dependent upon 
gout, syphilis and alcoholism. 



CHAPTER III. 

NEUROSES OF THE HEART. 

Paroxysmal Tachycardia — Palpitation of the Heart — Tachycardia 

Paroxysmalis. 

Etiology. Tachycardia is an abnormally frequent and forcible 
action of the heart, occurring in paroxysms that alternate with a healthy 
movement of the organ. It does not include those conditions of palpi- 
tation which occur in connection with valvular diseases and obstruction 
of the circulation. Two forms of the disease may be distinguished : 
1. Nervous palpitation. 2. Toxic palpitation. 

1. The nervous form of the disease is dependent upon cerebral 
excitement of a depressing character, e.g., fright, grief, worry, etc.; or 



NEUROSES OF THE HEART. 563 

it may be produced by nervous exhaustion dependent upon sexual 
excesses, chlorosis, loss of blood, prolonged lactation, excessive labor, 
hysteria, and neurasthenia. It is sometimes dependent upon actual 
disease of the brain or spinal cord, or upon tumors that exert pressure 
upon the roots or trunk of the pneumogastric nerve. Diseases of the 
digestive organs, errors of diet, constipated conditions of the bowels, 
intestinal parasites, hemorrhoidal disorders, gall-stones, renal calculi, 
uterine and ovarian disorders, have all been enumerated among the 
causes of cardiac palpitation. 

2. The toxic form of tachycardia comprises such cases as are 
dependent upon the introduction of morbid poisons into the circulation, 
or upon the retention of excrementitious matters. Tea, coffee, tobacco, 
alcohol, and various drugs like hemlock and henbane, are common 
causes of the disease. It is not unfrequent among the victims of gout. 

The disease occurs among children as well as among adults. Ex- 
cessive ambition in the pursuit of education, a rapid and slender 
growth of the body, and the occurrence of indigestion or intestinal 
parasites favor the manifestation of the disease in early life. 

The connection of the heart with the sympathetic and pneumogastric 
nerves indicates that palpitation may sometimes result from irritation 
of the first, and, under other circumstances, from temporary enfeeble- 
ment of the second. 

Symptoms. The principal symptom of paroxysmal tachycardia is 
furnished by the occurrence of attacks of palpitation in which the 
number and, usually, the force of the cardiac pulsations is increased. 
Such paroxysms may continue for a few minutes only, or for a number 
of hours. They may be separated by many minutes, or they may 
recur daily, or even many times a day. The disease may be limited 
by a single paroxysm, or it may continue through life. 

The paroxysm of palpitation is preceded not unfrequently by sensa- 
tions of distress in the cardiac region. The heart may beat feebly, 
as if about to cease from all motion. As the attack progresses there are 
sensations of pain, thoracic constriction, difficulty of respiration, 
accompanied by a feeling of anxiety; the countenance shows signs of 
distress, and is frequently covered with cold perspiration. Various 
symptoms of cerebral anaemia, accompanied by headache, are not 
uncommon. The cardiac pulsations are often irregular, frequent, and 
forcible, with wide diffusion of impulse over the precordial region. 
The systolic sound often assumes a metallic and vibratory quality that is 
occasioned by synchronous oscillations in the thoracic wall. Sometimes 
the first sound of the heart can be heard at a distance from the thorax ; 
it is accompanied frequently by a murmur which continues during 
the paroxysm and is dependent upon the molecular vibrations in the 
cardiac muscle. The second sound of the heart often becomes weak and 
almost imperceptible, and is accompanied by an imperfect filling of the 
arteries. In other cases the cardiac impulse is forcible, the carotid 
arteries beat vigorously, and there is complaint of a pressure of blood 
into the head. 

If a paroxysm continue for any considerable period of time, the heart 
exhibits signs of exhaustion, with retardation of the circulation ; the 



564 DISEASES OF THE ORGANS OF CIRCULATION. 

veins in the neck then become enlarged, and pulsate ; the rapidity of 
the pulse may become very great, sometimes numbering 250 beats in a 
minute. Such impulses do not always fill the arteries ; an intermission 
of the pulse at the wrist may then be observed. 

Respiration is always more or less disturbed by reason of nervous 
irritation and irregular circulation of the blood through the lungs. The 
diaphragm is depressed, either though direct irritation of the phrenic 
nerves, or as a consequence of their reflex excitation. The voice is 
hoarse, husky, or even reduced to a whisper. Difficulty of respiration 
is generally increased by the horizontal position, and the patient seeks 
relief in the erect posture. Sometimes the act of swallowing is attended 
with difficulty, and there may be painful distention of the abdomen 
which sometimes is relieved suddenly by vomiting and by the discharge 
of flatus, followed by a speedy termination of the paroxysm. A similar 
copious discharge of urine generally follows the conclusion of the attack. 
A fatal termination is a rare occurrence, though the patient commonly 
feels depressed and anxious through fear of its repetition. An irritable 
condition of the heart sometimes becomes established, with consequent 
predisposition to the symptoms of the disease. 

It sometimes happens that patients experience the subjective sensa- 
tions of palpitation without any actual disturbance of the heart other 
than a slight irregularity of the pulse. 

Pathological Anatomy. The rarity of death from palpitation of 
the heart limits our knowledge of the changes that may accompany its 
manifestation. Dilatation and atrophy, with fatty degeneration and 
induration of the connective tissue, have been observed in a few cases. 

Diagnosis. The disease may easily be recognized by its symptoms. 
From the rapid pulse that may accompany valvular disease it can be 
differentiated by the absence of endocardial murmurs and dilatation 
with hypertrophy of the organ. When the murmur is present during 
an attack of simple tachycardia it is of the systolic character, and if it 
persists beyond the conclusion of the paroxysm it is probably of a 
chlorotic or anaemic origin. Cardiac disturbances that are dependent 
upon chronic myocarditis are less easy to distinguish from taclwcardia. 
A differential diagnosis sometimes can be made only through long- 
continued observation of the patient and consideration of his ante- 
cedents. 

Prognosis. The prognosis will depend upon the nature of the 
cause. In many cases of a nervous character it may be easily re- 
moved, and the prospect of recovery is correspondingly good. Other 
cases depend upon incurable diseases, and admit of only temporary 
relief. 

Treatment. The indications for treatment are twofold : to relieve 
the paroxysm and to prevent its recurrence. Upon the onset of an 
attack the patient should be placed in a spacious, well-ventilated 
apartment, and the clothing should be loosened, so as to permit easy 
respiration. Sometimes a paroxysm may be promptly aborted by 
some extraordinary measure, such as pressure upon some particular 
locality in the abdominal Avail, or upon the pneumogastric nerve in the 
neck. Holding the breath after a deep inspiration, draughts of cold 



NEUROSES OF THE HEART. 565 

water, and sucking pieces of ice, sometimes give speedy relief. Some- 
times an ice-bag over the heart is found useful ; but it must not be for- 
gotten that some patients cannot tolerate cold, and are made worse 
rather than better by its application. The same thing must be re- 
membered in the recommendation of liquid nourishment ; some patients 
prefer exceedingly hot drinks, others are relieved by cold lemonade, 
aerated waters, or iced champagne. 

The first place among therapeutical remedies must be awarded to the 
hypodermic use of morphine, of which a quarter of a grain may be in- 
jected without the customary addition of atropine, since that drug 
sometimes occasions cardiac disturbance. Instead of morphine, other 
narcotics may be used, e. g , opium, chloral hydrate, ether, cherry- 
laurel water, tincture of hyoscyamus, tincture of aconite, strychnine, 
and ergot. Large doses of the bromide of potassium are sometimes use- 
ful. If the patient is of a nervous temperament, and is hysterically 
inclined, nervous stimulants may be employed, e. g., tincture of vale- 
rian (3ss every four hours), tr. assafoetida (5ss every four hours), 
chloride of gold and sodium (Ify. Auri et sod. chlorid., gr. v ; ext. hyos- 
cyam., 3ij. M. Ft. pil. no. xxx. S. — One pill after each meal), 
nitrate of silver (1^. Argent, nitrat., gr. v; argill., q. s. ut ft. pil. no. 
xxx. S. — One pill three times a day), zinc, valerianat. (gr. j three 
times a day), Fowler's solution of potassium arsenite (four drops after 
each meal). Sometimes an emetic occasions immediate relief by evacu- 
ating an overloaded stomach (1^. Apomorphiae, gr. one-tenth, aq. des- 
tillat., 5ss. M. S. — Inject hypodermically. 1^. Ant. pot. tart., gr. ss ; 
pulv. ipecac, sacch., aa gr. x. Div. in chart, no. iii. S. — Take one 
powder every ten minutes till vomiting occur). 

In order to avoid recurrence of tachycardiac paroxysms it will be 
necessary to consider their cause. The general health must be re- 
stored by attention to diet and exercise in the open air, with massage, 
and cold sponging. If the heart seems to be in any way enfeebled, the 
long continued use of digitalis will be found useful (Fol. digital, pulv., 
5ss.; ferri. carb. saccharat., 5yss ; pulv. althese, q. s. ut ft. pil. no. 1. 
S — Two pills after each meal.) Recently the choleinate of sodium, 
in doses of 1J grains every two hours, has been recommended, when 
digitalis fails to give relief. Change of occupation, and recreation at a 
distance from home, often exercise a favorable influence. Anaemic and 
chlorotic patients must be treated with iron and quinine. Hemor- 
rhoidal subjects who have experienced a suppression of the customary 
discharge, will be greatly relieved by the application of a few leeches 
around the anus. Female patients suffering with suppression of the 
menses, in like manner obtain great relief from the application of 
leeches, or cups upon the inside of the thighs. Vermifuges, purga- 
tives, and laxative mineral waters, will be found useful in appropriate 
cases. When thereis functional weakness of the nervous system the 
daily application of the galvanic current over the course of the pneumo- 
gastric nerve will prove advantageous ; the positive pole should be 
placed beneath the angle of the jaw, while the negative pole is applied 
lower down for two or three minutes upon each side of the neck. 



5(56 DISEASES OF THE ORGANS OF CIRCULATION. 

Paroxysmal Bradycardia — Bradycardia Paroxysmalis. 

By the term bradycardia is indicated a condition the opposite of 
tachycardia. The movement of the heart is retarded in force and 
frequency. The pulse becomes small and weak, the skin is cool and 
pale, and there is complaint of dizziness and faintness, sometimes asso- 
ciated with loss of consciousness, local spasms, or epileptiform convul- 
sions. The disorder is dependent upon nervous exhaustion, and is 
sometimes produced by the same causes that excite the phenomena of 
tachycardia in other patients. It is frequently associated with 
-polyarthritis and with fatty heart, or with sclerosis of the coronary 
arteries. Similar retardation of the pulse is sometimes observed in the 
course of exophthalmic goitre, instead of the usual acceleration of the 
cardiac movement. It is most successfully treated with cardiac 
stimulants. 

Intermittent Heart. 

Cardiac pulsation may sometimes be suspended for several seconds. 
This may be distinguished from simple irregularity of the heart by 
the fact that the cardiac contractions are regular so long as they con- 
tinue. Certain persons possess the power of voluntarily arresting the 
movements of the heart for a few seconds. This is supposed to be 
effected through the intervention of the nervous fibres that pass from 
the spinal accessory nerve to the pneumogastric trunk. These may be 
sufficiently excited by voluntary contraction of the cervical muscles to 
produce temporary arrest of the heart. 

Intermission of the heart may be produced by diseases of the cardiac 
muscles, such as fatty degeneration and hypertrophy. It may also re- 
sult from disease or exhaustion of the brain. It is not uncommon 
among elderly people after fatigue, especially if associated with imper- 
fect elimination of the excrementitious products of metabolism. 

Cardiac Neuralgia — Angina Pectoris — Stenocardia. 

Symptom?. — This disease is characterized by paroxysms of pain 
which originate in the nerves of the heart and extend into other ner- 
vous tracts. In some cases the paroxysms occur without any apparent 
cause ; in others they are preceded by indigestion, by excessive exertion 
of mind or body, or by exposure to cold. The onset of the attack is 
usually sudden, but sometimes it is preceded by various nervous disturb- 
ances that indicate derangement of the cerebral circulation, e. g.. dizzi- 
ness, buzzing in the ears, flashes of light before the eyes, nausea, diffi- 
cult deglutition, chilliness, formication, or change of color in the skin. 
The pain in the precordial region is often intolerable and indescribable : 
it is accompanied by a feeling as if death were about to occur. Severe 
neuralgic sensations are also experienced in the form of irradiations of 
pain into the left shoulder and arm, sometimes extending along the 
tracts of the nerves as far as the tips of the fingers. It may also 
involve the nerves in the neck and scalp, and it may be felt sometimes 
in the epigastrium, in the abdomen, in the ovarian region, and along 



NEUROSES OF THE HEART. 567 

the course of the spermatic nerves. It sometimes reaches the lower 
extremities and the opposite half of the body. 

The movements of the heart generally become accelerated, sometimes 
increased in strength, and sometimes enfeebled, with intermission of 
the pulse. Respiration also becomes disturbed and difficult, though 
there be no actual obstacle to inspiration or expiration. The counte- 
nance fully expresses the terrible agony experienced by the patient. 
Local spasms, sometimes reaching the height of epileptiform convul- 
sions, not infrequently occur. The territory of the pneumogastric 
nerve is especially liable to such disturbances. The participation of 
the sympathetic nervous system is shown by various disturbances of the 
vasomotor nerves. 

During the attack there is often a great desire for fresh air. The 
patient leans out of the nearest window and seeks to press the thoracic 
wall against some firm support. The conclusion of the attack is gener- 
ally accompanied by a copious discharge of clear and light-colored 
urine. If the paroxysm be considerably prolonged the signs of great 
prostration become apparent, and sometimes they may attain to the 
gravity of apparent death. 

The duration of the paroxysm is subj ect to great variation. Paroxysms 
may follow one another only after long intervals, or they may recur 
frequently for many days, The cessation of the paroxysm is some- 
times very abrupt ; in other cases it subsides gradually, with vomiting, 
evacuation of the bowels, or copious discharge of flatus. Sometimes 
there is cough and expectoration. 

The alternation of the cardiac paroxysm with paroxysms of other 
forms of neuralgia has sometimes been observed, so that the physical 
examination of the patient should not be limited to the heart, but 
should embrace all the organs of the body. During the interval 
between the paroxysms good health is frequently enjoyed, unless the 
predisposing cause be of a permanent character. Life is often pro- 
longed for many years, but death sometimes follows the gradual 
development of marasmus or cardiac debility. 

Etiology. — Angina pectoris is observed most frequently among old 
people after their fiftieth year. It is a disease of males rather than of 
females, for the reason that men are more liable to gout, rheumatism, 
fatty degeneration of the heart, and atheromatous degeneration of the 
bloodvessels, with which cardiac neuralgia is often associated. The 
use of tobacco and alcohol is also more common among men than 
among women. Obesity and luxurious living are powerful predispos- 
ing causes. Cold and damp weather is a frequent exciting cause of the 
disease. 

Those cases of angina pectoris which occur without any recognizable 
organic diseases of the internal organs constitute what is termed the 
essential form of stenocardia. All cases that are connected with 
organic diseases that involve the circulatory apparatus are comprised 
under the term symptomatic stenocardia. 

Diagnosis. — Angina pectoris is easily recognized by attention to 
the symptoms. 



= 



DISEASES 0¥ "HE ORGANS OF CIRCULATION. 

Pec inosis. — The ignosis lepen la m the nature of the prr lia- 
ising : wses " is : von lie, when they admit of easy and permanent 
removal. It is always wise, however, : : se great caution with re- 

sa rd to the future. 

Treatmest. — The general treatment of the paroxysm is the same 
that has t Ben : i es ::;': e I for the relief of tachycardia. The hypodermic 

ion :>: morphine Ere lently irrests the attack, though the da: _ 
which attends its use : ises that are le -..lent upon a fatty condition 
of the heart must not be forgotten. Inhalation of chloroform, which 
has been frequently practised, ifi i langerous remedy^ the use of which 
has been followed by epileptiform convulsions and collapse. Inhala- 
tion jfamyl nitrite is attended with less danger, since it is suppose 1 :: 
stimulate the cerebral circulation. It may be poured in five-drop 
upon a handkerchief, from which it can be easily inhaled ; on account if 
its explosive nature it should not be brought near a fire or a light. 
>~.:.: -glycerin, in Jro| loses :: a one prr sent. solution, may be given 
every few minutes until it produces effects similar :: those of amyl 
nitrite C : saine hydrochlorate may be ^iven, in doses of a third or a 
half of a grain, three :; four times a day for twc h three days. Its 
effect is m : i e gi " I y leveloped than that of the prece . : n g i e m sdies. 
Fhe hypodermic injection of antipyrine. in fifteen-grain loses, often 
gives great relief sometimes even after thefailuiT :: m;rphine. 

Symptoms of heart failure should ': e >pposed by the use :f cardiac 
stimulants. Mustard foot baths, and the application of mustard to 
the precordial region, or the use of dry cups upon the thoracic 
surface, are very effectual. 

symptoms of vasomotor disturbance maybe relieved by warm baths 
and by friction with chloroform liniment 

R — Ir aeonit. ra<L \ -.. 

Tr. belladon. f *" °_ 1J " 

Tr. g. camphor. . . . . j|ss 

Chloroform. ........ ^j 

Lin sapon. . . . . . ■ 5 "\ — -^ 

BL — Airly externally. 

A tendency to recurrence : the ae nralmc n must be obviated 

by attention to the general health, i e.. by regulation of the diet, daily 
movement of the 1 d air. massage, cold spong- 

ing, light gymnastics, and sum: thing tc the injni 

effects of cold. Org approprii nent. 

thetic and pneumogastric nerves is also use- 
ful. Change :;eficial when it can be procured without 
rifi js. 

Exophthalmic Goitre — Tachycardia Strumosa Exophthalmic a. 

SYMPTOMS. — Ti. .ent symptom- fes ohthalmic goitre are an 

- in the number of the > t ;, 4 U >f the thy- 

of the eyeballs, * if the 

- - it. The pulsations some- 

ii even 200 in a minute. Thev sometimes exhibit 



NEUKOSES OF THE HEART. 



569 



paroxysmal acceleration associated with pain and subjective difficulty 
of respiration. In rare cases the movements of the heart are abnor- 
mally retarded. Dilatation and hypertrophy of the heart are occasion- 
ally observed, as well as systolic murmurs, which are usually of a func- 
tional character ; though sometimes chronic diseases of the heart may 
be associated with the neurosis. 

Acceleration of the heart often precedes thyroid enlargement. The 
gland is at first soft and compressible, sometimes exhibiting pulsatory 
movements ; but, after a time, it becomes firmer and more consistent. 
The arteries and veins become dilated and serpentine. (Fig. 118.) 

Fig. 118. 




Exophthalmic goitre. (Rush Medical College Clinic.) 



Protrusion of the eyeballs is usually one of the later symptoms of 
the disease. It sometimes occurs upon one side only. Simultaneous 
development of these symptoms sometimes occurs ; but usually they 
succeed one another in a regular manner. 

Tremor is sometimes partial and sometimes universal ; it may be 
constant, or it may be manifested only during certain movements of the 
body or limbs. The diminished resistance of the skin to galvanic cur- 
rents has been ascribed to an increase in the activity of the sweat 
glands. 

The larger arteries throughout the body frequently exhibit an 
increase of pulsation associated with various systolic murmurs. The 
veins of the neck not unfrequently pulsate. The force of the pulse 
exhibits great variation. 

A general increase of glandular activity throughout the body is 
often observed, so that vomiting or profuse diarrhoea are not uncom- 
mon. Hemorrhages from the various mucous membranes are sometimes 
observed. As a consequence of perverted nutrition, the shin sometimes 
becomes discolored or thickened. Urticaria, vitiligo, sclerema, and 
gangrene of the lower extremities have all been observed. 

The victims of exophthalmic goitre are generally of a delicate con- 



570 DISEASES OF THE ORGANS OF CIRCULATION". 

stitution, and of a blonde complexion. The countenance manifests an 
expression of astonishment, accompanied by a staring look, which is 
produced by the protrusion of the eyeballs, and by the fact that the 
upper eyelid does not reach the border of the cornea, but leaves a space 
in which the white, sclerotic coat of the eyeball is visible. Occasion- 
ally the protrusion of the eyeball is so great that the eyelids close behind 
instead of upon it ; by reason of such exposure, inflammation and ulcer- 
ation of the cornea not unfrequently occur. A symptom of consider- 
able diagnostic importance lies in the fact that the movements of the 
upper eyelid do not coincide with changes in the position of the visual 
plane. This is due to a spasmodic contraction of the unstriated mus- 
cular fibres in the upper eyelid (Miiller's muscle). 

The disease is frequently observed among epileptic, hysterical, or 
hypochondriacal patients. Mental derangements sometimes occur, and 
an unusual cheerfulness is a not uncommon symptom. 

Exophthalmic goitre is frequently associated with neuralgia of the 
cranial nerves. Hemi-ansesthesia, paresthesia, chorea, ophthalmople- 
gia, and paralytic affections of the other cranial nerves, have been 
observed, as well as paralytic affections of the extremities. Progressive 
muscular atrophy and pseudo-muscular hypertrophy sometimes occur. 
The sensations of hunger and thirst are often greatly increased. The 
bodily temperature may be slightly elevated, and patients often complain 
of a subjective sensation of heat. 

The disease usually develops gradually, and is of long duration. It 
is an uncommon thing for it to be introduced by a febrile attack. 
When recovery takes place the prominence of the eyeballs is the last 
symptom to disappear. Chronic cases usually fall into a condition of 
cachexia ; sometimes the circulation suffers obstruction, and the phe- 
nomena of dropsy are developed. Intercurrent diseases are sometimes 
the cause of death. 

Etiology. Exophthalmic goitre occurs about twice as often among 
women as among men, especially among delicate, blonde, blue-eyed, 
chlorotic, and anaemic persons who also suffer with nervous weak- 
ness and menstrual derangement. It is a disease of early adult life, 
occurring most frequently between the fifteenth and thirtieth years. 
Like other disorders of the nervous system, it is common among indi- 
viduals who are descended from a neurotic ancestry. Unfavorable 
conditions of climate, occupation, and hygienic environment, concur 
with the effects of mental and physical exhaustion or previous disease, 
to favor the development of exophthalmic goitre. 

Pathological Anatomy. Hypertrophy and dilatation, endocar- 
ditis, and fatty degeneration of the cardiac muscles, have sometimes 
been discovered after death. The connective tissue and parenchyma 
of the thyroid gland are increased. Its arteries are dilated, and the 
veins are varicose. The retro-bulbar tissues are infiltrated with fat, 
and their bloodvesssels are dilated. The ocular muscles sometimes 
exhibit fatty degeneration. The central nervous system may, or may 
not, exhibit different changes which present no uniformity, and cannot 
be connected with the symptoms of the disease. The opinion of Char- 
cot, that exophthalmic goitre is a general neurosis, comparable with 



NEUROSES OF THE HEART. 571 

hysteria, expresses as accurately as any, the opinion of the majority of 
observers. Recent experiments upon lower animals, which indicate 
that many of the symptoms of the disease can be produced by irritation 
of the restiform bodies, seem to favor the theory that the disease is the 
expression of a condition characterized by excitation of the accelerator 
nerves of the heart and of the vaso-dilator nerves connected with the 
vessels of the head and neck. A similar excitation extending to the 
fibres of Miiller's muscle and to the dilator fibres of the pupil may suf- 
fice to explain the condition of the eyes. 

Diagnosis. The diagnosis cannot present any difficulty when all 
the symptoms are present. A persistently frequent pulse, that cannot 
be explained by other causes, should lead to a suspicion of the imminent 
development of the disease. 

Prognosis. The prognosis is not very favorable. Sometimes 
apparent recovery is followed, after a considerable period, by a relapse. 
When the disease occurs in the person of a male it is more unfavorable 
than in a patient of the opposite sex. 

Treatment. The treatment of exophthalmic goitre is both local and 
general. 

The general treatment must be directed to the improvement of the 
health and constitution of the patient. For this purpose may be recom- 
mended the long-continued administration of iodide of iron in the form 
of pills or of the syrup. The constant current, from five to ten battery 
cells, should be applied daily through the neck and upper part of the 
thorax ; the negative pole should be placed over the upper part of the 
neck, while the positive pole rests between the shoulder-blades. The 
negative pole may also be placed over the thyroid gland and along the 
course of the sterno-cleido-mastoid muscles. The current should be 
allowed to pass for two minutes in each position. 

If menstrual derangements exist they should be regulated by appro- 
priate measures; and amenorrhoea must be overcome by the employ- 
ment of mustard foot-baths, with leeches, or cupping-glasses, upon the 
insides of the thighs. Marriage has sometimes been observed to 
exercise a favorable effect upon the course of the disease. Long- 
continued daily massage is also of great value. Change of locality 
and the use of mineral waters that contain iron, are frequently beneficial. 
Distressing palpitation of the heart may be relieved by the ordinary 
methods of treatment (ice-bags over the heart; infusion of digitalis, 
a tablespoonful every two hours, etc.). 



Dl'l DISEASES OF THE ORGANS OF CIRCULATION. 



CHAPTEE IY. 

DISEASES OF THE PERICARDIUM. 

Pericarditis. 

Pathological Anatomy. Pericarditis mav be described, according 
to its extent, as either a circumscribed or a diffuse inflammation of the 
pericardium. The circumscribed form of the disease affects the basal 
portion of the heart and its large vessels, while the diffuse form 
extends over the epicardial surface and the opposite wall of the peri- 
cardium. Since there is no difference in the character of the inflam- 
matory processes, one common description will suffice for both forms 
of the disease. 

The first appearances of change consist in an increased turgidity of 
the capillary vessels. The pericardial surface appears reddened and 
hypertemic. Minute extravasations of blood may be observed at different 
points. The polished surface of the pericardial lining becomes tar- 
nished and roughened, and it is soon overlaid with a thin layer of 
exudation. This gradually becomes thicker and partially organized, 
constituting a yellow or gray investment that covers the entire surface 
of the pericardium, and on inspection reminds one of the honey-combed 
appearance of tripe from the second stomach of the calf, or of the 
roughened surfaces that are produced by the sudden separation of two 
thickly buttered slices of bread In advanced cases of the disease the 
movements of the heart within the pericardium produce a stringy or 
roughened appearance in the partly organized membranes that have 
been subjected to friction against each other. In this way are produced 
the so-called hairy hearts described by ancient authors, constituting 
what is now called pericarditis fibrinosa. 

Besides its solid constituents the inflammatory exudation usually con- 
tains a considerable amount of liquid which may be either of a sero- 
purulent or hemorrhagic character. The most common form is the 
sero-fibrinous variety, which constitutes not less than two-thirds of the 
cases. In this form of the disease the liquid portion of the exudation 
is composed of transparent serum that contains a few clouded cells and 
fibrinous filaments. 

Purulent pericarditis is characterized by an exudation of a purulent 
character, which often distends the pericardium to a capacity of three 
or four quarts, producing serious encroachment upon neighboring 
organs. 

Hemorrhagic pericarditis usually occurs in connection with diseases 
marked by grave dyscrasia, such as cancer, tuberculosis, scurvy, and 
the hemorrhagic varieties of the eruptive diseases. 

The results and consequences of pericarditis may be very numerous. 
The subpericardial structure of the heart may undergo fatty degenera- 



DISEASES OF THE PERICARDIUM. 573 

tion, while the deeper layers of the muscular tissue of the organ may 
also exhibit signs of inflammatory infiltration with small round cells. 

Purulent 'pericarditis is sometimes accompanied by the development 
of an ulcerative process in the pericardial tissue which may occasionally 
invade the superficial layers of the heart. The purulent contents of the 
heart sac sometimes find their way through the adjacent tissues into 
neighboring cavities within the thorax, or they may reach the surface 
through the establishment of a pericardial fistula. 

The inflammatory process sometimes extends to the external surface 
of the pericardium, constituting pericarditis externa. In this way the 
mediastinal connective tissue and the pleural surfaces may become 
involved. 

When purulent pericarditis has been occasioned by the extension of 
a cancerous growth from the walls of the stomach or from the oesophagus, 
or when a purulent cavity within the lungs has effected a communica- 
tion with the heart sac, the contents of the pericardium may undergo 
decomposition, constituting a putrid pericarditis. This always indi- 
cates the introduction of air within the pericardium, and the consequent 
invasion of its contents by the microorganisms of putrefaction. 

In many cases the walls of the pericardium remain permanently 
thickened. Sometimes the products of fibrinous exudation become 
organized into polypous masses which cover the whole surface with 
tuft-like processes. Occasionally one of these becomes detached, and 
may be found lying free within the cavity of the pericardium. 

It very often happens during the course of pericarditis that the 
opposite surfaces of the heart sac become adherent through the forma- 
tion of organized bands of connective tissue. In the course of time 
these may be ruptured by the movements of the heart, leaving visible 
traces of their presence upon the opposite surfaces. Sometimes, how- 
ever, complete and permanent adhesion takes place. Sometimes the 
fluid portion of the exudation is not absorbed, and the pericardial cavity 
is permanently occupied by a spongy network whose meshes are filled 
with a serous or purulent liquid. After a time the fluid portion of the 
pus may be absorbed, leaving a residuum that can become infected with 
tubercle bacilli, and be converted into a cheesy mass, constituting tuber- 
culous pericarditis. In certain cases this caseous deposit may undergo 
calcification, so that the heart may be actually surrounded by a cal- 
careous investment. 

Symptoms. The impossibility of recognizing pericarditis through 
an investigation of subjective symptoms renders it of importance that, 
in all cases of articular rheumatism and other predisposing diseases, 
the heart should be frequently examined. The indications of pericar- 
ditis may be divided into three groups: 1. Special symptoms. 2. 
Physical signs. 3. General symptoms. 

1. Special symptoms. There are three special signs of pericarditis, 
namely: pericardial friction sounds; extension of pericardial dulness 
on percussion; and disappearance of the apex beat of the heart. Fric- 
tion sounds are obviously dependent upon fibrinous exudation. In- 
creased dulness on percussion and suppression of the apex beat depend 
upon the fact of exudation without regard to its quality. The extent of 



574 DISEASES OF THE ORGANS OF CIRCULATION, 

the territory within which friction sounds are audible gives no certain 
indication of the extent of the inflammatory process. In like manner 
the existence of friction sound is not a positive indication of pericarditis, 
since it may be produced in certain very rare cases of tubercular and 
cancerous disease, or calcification of the coronary arteries, or great en- 
largement of the heart, and excessive dryness of the pericardial surface 
itself may originate a friction sound; but in the vast majority of cases 
such sounds have no other cause than fibrinous exudation within the heart 
sac. The quality of the sound is always exceedingly variable. It may 
be very soft, or it may be very loud, with a creaking like that produced 
by the bending of new leather. It may acquire a metallic quality, if 
the stomach or any other neighboring cavity be distended with air. It 
sometimes is intermittent, and it may exhibit an increase of intensity 
in correspondence with the contraction of the auricles and the contrac- 
tion and dilatation of the ventricles. In certain cases it resembles the 
fine, crepitant rales that are produced in pulmonary inflammation. 
Variations of pressure upon the thoracic wall, e. g.. with the tube of the 
stethoscope, may produce corresponding variations in the strength of 
the sounds, since it is evident that the effects of friction must vary as 
the opposite surfaces of the inflamed pericardium are brought nearer 
together. In this way, by the exertion of too great force, it is possible 
to suppress the sounds altogether. Variations in the position of the 
body, and the movements of respiration, exercise a similar influence. 

The duration of friction sounds depends upon the length of time 
during which the pericardial surfaces are in contact with one another. 
It often happens that the sound which was audible at the commence- 
ment of the disease soon becomes suppressed by the occurrence of ex- 
udation, and is renewed only after the absorption of the liquid products 
of inflammation. 

Fig. 119. 




Percussion dulness in pericardial effusion : the lower and left margins left undefined, 
owing to their having been inseparable from the dull percussion of the abdomen and of 
the left pleura. (Gairdxer). 



The extent of pericardial dulness depends upon the amount of 
exudation. (Fig. 119.) The form of the distended heart sac. as 
determined by percussion, will depend somewhat upon the extent to 



DISEASES OF THE PERICARDIUM 575 

which the lungs and the mediastinal connective tissues can be pushed 
aside. In cases of extensive exudation, dulness may be discovered as 
high as the first costal cartilage upon the left side, and as far outward 
as the left axillary line ; while upon the right side it may reach as 
far as the mammary line, and downward as low as the eighth rib upon 
the left side. In such cases the heart may be felt in the epigastrium, 
or in the left hypochondriac region. The triangular shape of the region 
normally occupied by cardiac dulness becomes thus transformed into 
an irregular trapezoidal figure, with its longest side directed downward. 

From what precedes, it is evident that the apparent force of the 
apex beat of the heart must necessarily diminish with the progress of 
exudation which presses the heart away from the thoracic wall. Such 
failure of the apex beat may be distinguished from a similar condition 
in other cardiac diseases by the fact that the pulse remains full and 
strong in uncomplicated pericarditis, while it becomes weak and faint 
in other cardiac diseases. 

2. Physical signs. Inspection indicates unusual prominence of the 
precordial region ; the intercostal surfaces are enlarged ; the left 
nipple consequently stands above the level of the right ; the skin ap- 
pears smooth and glossy ; the subcutaneous veins become more conspic- 
uous than usual. Such changes are more easily developed in children 
and in women than in men, whose thoracic walls are less yielding. 
The movements of respiration are greatly reduced upon the left side of 
the thorax. The movements of the heart produce no distinctly visible 
impulse. The large veins of the neck are distended, and sometimes 
exhibit pulsatory movements. 

The position of the patient is worthy of note. He must either lie 
with his shoulders elevated, or upon his left side ; a position upon the 
back or upon the right side occasions great difficulty of respiration, 
through compression of the right lung, with which respiration is chiefly 
performed. 

Palpation indicates a greater tension in the skin upon the left side 
of the thorax than upon the right side. The subcutaneous areolar tis- 
sue is sometimes oedematous through the production of collateral 
oedema, dependent upon the pericardial inflammation. Vocal fremitus 
is abolished over the region of dulness, and fluctuation has been ob- 
served in cases marked by a wide separation between the costal carti- 
lages and ribs. 

Percussion indicates great extension of dulness around the heart. 
In cases of extensive exudation it may be difficult to distinguish be- 
tween the pericardial border and the adjacent portion of the compressed 
lung ; but from pleurisy with exudation this dulness may be distin- 
guished by an increase of vocal fremitus, which, on the contrary, is 
weakened in pleurisy. From pneumonia the condition of simple com- 
pression of the lung may be distinguished by the absence of crepitant 
r&les, though dulness and bronchial breathing are common to both con- 
ditions. A tympanitic percussion sound ordinarily characterizes the 
state of compression to which that portion of the lung is subjected that 
lies in contact with the distended pericardium. 

Auscultation indicates an apparent diminution of the heart sounds, 



0,6 DISEASES OF THE ORGAXS OF CIRCULATION". 

which is dependent upon the intrusion of liquid between the heart and 
the thoracic wall. Systolic murmurs are frequently audible, and have 
their origin either in fever, defeneration of the muscular fibres of the 
heart, compression of the large arteries, or endocardial inflammation. 

3. The general symptoms of pericarditis possess less importance 
than the above-mentioned signs. Subjective symptoms are of very 
little significance. Pain is sometimes felt in the precordial re_ 
especially when there is but little fluid exudation. It sometimes extends 
into the back, left arm. or the abdomen, and it is sometimes increased 
by pressure over the region of the heart and along the left border of 
the epigastrium. Palpitation of the heart, difficulty and rapidity 
of respiration, frequently occur as a consequence of hindrance to the 
pulmonary circulate 

Fever and elevation of temperature occur in the majority of cases, 
but may be entirely absent, even in purulent pericarditis. The pulse is 
usually frequent and strong, though often irregular. In the later 
rse of the disease its vigor may be diminished as the muscular struc- 
ture of the heart becomes injured. The urine is generally scanty and 
high colored, with acid reaction, and deposits a sediment of urates when 
1 Albuminuria is frequently present. If the circulation of 
siderabry imped- i. oedema and general dropsy may occur. 
Death sometimes happens as a consequence of sudden heart failure 
produced by dropsical conditions of the brain. In other cases, cerebral 
hypeneruia may exist, and death may be preceded by delirium or 
convulsions and coma. 

I: occasionally happens that difficult swallowing, hoarseness, hiccough, 
and vomiting may be produced by pressure upon the oesophagus or 
upon the pneumogastric or phrenic nerves. 

The duration of pericarditis is exceedingly variable. Occurring in 
itic subjecis. it may destroy life within twenty-four hours. When 
the amount of fluid exudation is small it may be healed in a few days. 
If it continues longer than four weeks, it may be called a chronic in- 
flammation. Recovery is indicated by the gradual subsidence of the 
symptoms and physical signs of the disease, but it occasionally 
ens that through the contraction of adhesions the pericardial 

_ d becomes abnormally depressed and retracted. The cardiac nerves 
remain for a lung time excessively irritable, so that the movemei;:- : 
the heart are easily excited by trifling causes. 

Etiolooy. /'■ < may result from traur tes which 

I ice injury of the thorax : and it is often associated with articular 
v/<. usually following inflammation of the joints, though some- 
times preceding that process. It is also a not infrequent complic 
of tli- *, such as are produced by 

renal a 3 . cancer, pulmonary consumption, alcoholism, scurvy, and 
purpura hemorrhagica, favor its occurrence. It may be product 
an extern _ *.s to 

the pericardium. Abicetset m and other adjacent 

- may rupture into the pericardium, and thus produce inflamma- 
ts structure. Other die - - f the pericardium, e. g. to 
I - r, may excite pericardial inflammation. 



DISEASES OF THE PERICARDIUM. 577 

The actual process of inflammation is probably excited by the 
presence and activity of microorganisms which have invaded its struc- 
ture. Streptococcus pyogenes and staphylococcus pyogenes aureus 
have been frequently found in the tissues, and the pneumococcus has 
been discovered in the exudations of pericarditis. 

The disease occurs most commonly between the fifteenth and thir- 
tieth years of life, and attacks males more frequently than females. 

Diagnosis. The recognition of pericarditis is very easy when the 
three principal symptoms previously enumerated are present. It must 
be remembered, however, that friction sounds may be mistaken for 
endocardial murmurs, especially when the first are faint and the last 
are unusually loud. Pericardial sounds are increased by moderate 
pressure, while endocardial sounds remain unchanged. A degree of 
pressure that interferes with the movements of the heart will suffice to 
weaken both sounds. Deep inspiration almost always diminishes an en- 
docardial murmur but increases a pericardial friction sound. Sounds 
that are induced by the assumption of an erect position, or by leaning 
forward, are generally of pericardial origin. Endocardial murmurs are 
also closely connected with the movements of the heart, and are either 
systolic, diastolic, or presystolic, while pericardial sounds do not 
always exhibit such accurate coincidence. 

Friction sounds sometimes have their origin upon the pleural or 
peritoneal surfaces in the neighborhood of the heart, and they some- 
times are connected with the movements of that organ as well as with 
the respiratory movements. They are increased by deep inspiration 
and expiration, by which their pleuritic character becomes evident. 

Previous adhesions that have been caused by a former attack of 
pericarditis may hinder the development of friction sounds, but they 
•can sometimes be excited by changes of position or by pressure over the 
pericardium. 

The existence of adhesions between the anterior surface of the heart 
and the pericardial wall may prevent the occurrence of the character- 
istic dulness that is caused by pericardial effusion. The liquid exuda- 
tion then occupies the posterior portion of the heart sac, and cannot be 
discovered by percussion. A similar difficulty arises when an emphy- 
sematous condition of the lung interferes with the lateral extension of 
pericardial dulness. 

A coincident encysted pleurisy or an inflammation of adjacent por- 
tions of the lung may interfere with the accurate estimation of a peri- 
cardial effusion ; but the presence of increased vocal fremitus, bronchial 
breathing and sonorous rales will assist in a definition of the extent 
of the pulmonary disease. Aneurismal and mediastinal tumors may 
be distinguished from pericardial enlargement by their different history 
as well as by their characteristic symptoms. Great enlargement of the 
heart may be distinguished from pericarditis by the fact that dulness 
on percussion remains unchanged in the upright position in the first 
disease, while in the last it extends farther upward when the patient 
stands erect. In pericarditis also the apex beat is weak or imper- 
ceptible, and does not coincide with the limit of dulness, though the 

37 



578 DISEASES Of THE ORG AX S OF CIRCULATION. 

pulse remains full and strong. The heart sounds also seem diminished 
when there is considerable effusion into the heart sac. 

The character of the exudation in pericarditis cannot be determined 
by the physical signs ; it must be inferred from the antecedents and 
complications of the case. Occurring in connection with acute rheuma- 
tism, the exudation is usually of a sero-fibrinous character. Pyaemia 
and septicaemia give rise to purulent pericarditis. In cases of scurvy, 
cancer, tuberculosis and the hemorrhagic diathesis, the pericardial con- 
tents may be of a bloody character. The existence of hydro-pericardium 
may be inferred from the existence of obstruction to the circulation of 
blood, and from other causes of dropsy. Exploratory aspiration will 
reveal the character of the fluid. 

Prognosis. The prognosis in rheumatic pericarditis is favorable, 
but other forms of the disease are attended with great danger. Infancy, 
old age, and conditions of constitutional enfeeblement influence the 
prognosis very unfavorably. The disease is more dangerous among 
women than among men. The chronic form of the disease is more to 
be feared than the acute variety on account of its deleterious influence 
upon the nutrition of the muscular structure of the heart. 

Treatment. The treatment of the acute, uncomplicated form of the 
disease consists in the adoption of dietetic and locally antiphlogistic 
measures. The patient should be placed in a large and well-ventilated 
apartment where the temperature can be maintained at 70° F. : and 
the air, when artificial heat is employed, should be kept moist by the 
evaporation of water. The patient must preserve the recumbent posi- 
tion, in order to avoid the danger of fatal syncope on rising up in bed. 
For this reason a bedpan must also be provided for the use of the 
patient, and constipation must be avoided by the use of compound 
rhubarb pills or large injections of water, if needed. 

During the first fortnight the diet must consist of milk, eggs, broths, 
and gruel. Lemonade and other acid drinks may be allowed. Stewed 
fruit is useful to prevent constipation. Coffee and tea must be pro- 
hibited, on account of their tendency to excite palpitation of the heart, 
but the cautious use of wine and beer may be permitted, and should be 
positively recommended in chronic cases attended by debility and defi- 
cient nutrition. As the case progresses, a more substantial diet should 
be ordered — e. g., the white meat of poultry, game, scraped beef, thin 
slices of ham, tender veal cutlets, sweetbreads, and calves' brains. 

Local antiphlogistic treatment requires little more than the continued 
application of an ice-bag over the precordial region. This moderates 
the action of the heart, and prevents palpitation. If the cardiac move- 
ments are not sufficiently diminished by local treatment, digitalis may 
be prescribed. 

R. — Potass, nitrat. §ss. 

Infos, fol. digital. I 1 

Syr. simpl. ........ 5>s. — M. 

S — A tablespoonful every two hoars. 

A tendency to constipation may be obviated by the substitution of 
the bitartrate of potassium for the nitrate of potassium. If digitalis 



DISEASES OF THE P E RIC A R DI U M . 579 

cannot be tolerated, or if its toxic effects are developed, it must be dis- 
continued, and it may be replaced by one of its substitutes. For this 
reason the patient should be frequently examined during its adminis- 
tration. 

The appearance of cardiac weakness will indicate the employment of 
stimulants. Wine or spirits may be given in small and frequent doses 
as required. If that prove insufficient, it may become necessary to 
administer five or ten drops of ether on sugar every fifteen minutes, or 
a grain of camphor may be given every hour ; or the drug may be used 
hypodermically. 

R . — Camphor, gum. gr. xv. 

01. amygdal Jij. — M. 

S. — 3 SS when needed. 

If the disease is attended with severe pain in the precordial region, 
great relief may be obtained from the application of several leeches over 
the seat of suffering. The skin should be thoroughly washed, and 
moistened with a little sweetened milk, and should be punctured with 
the point of a lancet wherever a leech is to be applied. Their number 
and the amount of bleeding that is to be permitted should depend upon 
the vigor of the patient. When the leeches have ceased to draw blood, 
its additional flow may be favored by the application of salicylated 
cotton that has been dipped in warm water. Excessive bleeding may 
be controlled by the application of styptics. If leeches cannot be pro- 
cured, good results may be secured by the application of cupping- 
glasses, or a cantharidal plaster about three inches wide and four inches 
long. When this has produced a blister, its serous contents may be 
evacuated by snipping the skin with a clean pair of scissors, and the 
surface may then be dressed with a five per cent, carbolized oil or salve. 

Severe vomiting, hiccough, and difficult deglutition, or the occurrence 
of great sleeplessness and distress, require the hypodermic use of 
morphine and atropine. 

R .— Morph. sulph gr. \. 

Atrop. sulph gr. T £ T . 

Aq. destill 3 ss.— M. 

S. — Inject every three or four hours. 

The occurrence of fever may be treated by the administration of ten 
grains of phenacetine, or five grains of acetanilide every two hours, until 
the subsidence of febrile symptoms. Antipyrine, quinine, and the sali- 
cylates should be avoided on account of their debilitating influence. 

Tardy removal of the exudation may demand the use of iodide of 
potassium, which may be given in small doses in connection with digi- 
talis. 

Be. — Potass, iodid. . . . • . . . . Bijss. 

Pulv. fol. digital gr. viij. 

Excipient. q. s. ut ft. pil. no. xxx. 
S — One or two pills three times a day. 

The precordial region may be painted with the tincture of iodine, or 
may be treated with repeated blisters. If these measures fail of sue- 



580 DISEASES OF THE ORGAXS OF CIRCULATION 

cess, diuretics and laxatives must be employed. Diaphoretics are 
objectionable on account of their tendency to produce palpitation, dys- 
pnoea, and collapse. The infusion of adonis vernalis, in doses of a table- 
spoonful every two hours, and the hypodermic administration of the 
sodio-benzoate of caffeine night and morning, are highly recommended. 

When the exudation cannot be removed by such therapeutical 
measures, if alarming symptoms threaten the life of the patient, it may 
be necessary to perform paracentesis of the pericardium. This may be 
accomplished by simple puncture in the fifth intercostal space, about an 
inch from the left border of the sternum. The operation must be per- 
formed in accordance with the method employed in pleurisy. If the 
pericardial effusion is of a purulent character, it should be evacuated 
through a free incision at the point where the pericardium lies in imme- 
diate contact with the thoracic wall. 

During convalescence from pericarditis the patient must be restrained 
from too early assumption of the erect position, for fear of dangerous 
syncope. All forms of excessive excitement must be avoided for a long 
time. 

Pericardial Adhesion — Synechiae Pericardii. 

It not unfrequently happens that as a consequence of scro -fibrinous 
pericarditis, more or less complete adhesions are established between 
the opposite pericardial surfaces. These may sometimes disappear as 
a consequence of the movements of the heart, or they may persist through 
life. Sometimes, also, it happens that the external surface of the peri- 
cardium becomes adherent to the thoracic wall, or to the spinal column, 
and the adjacent organs. As a consequence of these adhesions the 
anterior wall of the chest may become retracted, the movements of the 
heart may be seriously hampered, and the passage of blood through the 
aorta and the innominate veins may be considerably obstructed. Under 
these conditions the phenomena of retrograde pressure may be developed 
in the course of the circulation, viz., palpitation of the heart, rapid, 
weak, and irregular pulse, oedema, scanty secretion of urine, slight 
albuminuria, enlargement of the liver, general dropsy, bronchial catarrh, 
hemorrhagic infarcts in the lungs, dyspnoea, and cyanosis. The phys- 
ical signs, when they exist, are often very obscure. It is only possible 
to arrive at the diagnosis with certainty when the patient has been 
under observation from the commencement of the disease ; or when 
there is considerable retraction of the precordial region during cardiac 
systole, associated with collapse of the large veins in the neck during 
the diastolic movement of the heart, a symptom which is produced by 
the forward protrusion of the thoracic wall and the consequent extra- 
ordinary aspiration of blood into the right auricle during diastole. 

Treatment of pericardial adhesions cannot be undertaken with any 
hope of cure. Special symptoms of cardiac failure, or of obstruction of 
the circulation, must be treated as they appear, in accordance with the 
rules that have been given on previous pages. 

It sometimes happens that by reason of the extension of the in- 
flammatory processes, the connective tissue of the mediastinum becomes 
involved, with the production of adhesions or callosities by which the 



DISEASES OF THE PERICARDIUM. 581 

great vessels of the heart may become adherent to the sternum or to 
the spinal column or oesophagus, constituting what has been described 
as Mediastino-pericarditis fibrosa s. callosa. The existence of this 
condition may sometimes be recognized by the occurrence of swelling in 
the veins of the neck, and by variations in the pulse during inspiration, 
constituting what has been described as pulsus paradoxus (Fig. 120). 

Fig. 120. 



" Pulsus paradoxus." I, inspiration ; E, expiration. (After Kussmaul.) 

This is characterized by the diminution or total disappearance of the 
arterial impulse during deep inspiration. The coincident swelling of 
the cervical veins is caused through compression of the innominate 
veins by the mediastinal adhesions which are brought into a condition 
of increased tension during the act of inspiration, thus interfering with 
the aspiration of blood into the right auricle and its passage through 
the aorta during the expansion of the chest. 

Hydro-pneumopericardium. 

Besides the ordinary liquid exudations, the pericardium may some- 
times contain air or gas. This may find entrance through external 
wounds or injuries of the thorax, or as a consequence of the establish- 
ment of a communication between cavities in the lungs, or a pyopneu- 
mothorax, and the pericardium. Ulcerations of the stomach may also 
find their way to the pericardium and result in the admission of air 
within its cavity. It is probable in all cases of pneumopericardium 
without evident opening of the air sac, that such an opening has at 
some time existed, or has been overlooked. It is possible that the gases 
of putrefaction might accumulate within the pericardium after death, in 
certain cases In such instances the appearances of inflammation would 
be absent. 

Symptoms. The physical signs of air in the pericardium are char- 
acterized by prominence of the precordial region, with absence of the 
cardiac impulse and vocal fremitus. There is tympanitic resonance on 
percussion, with the development of a metallic tone, that is most evident 
during auscultatory percussion; and the occurrence of a splashing 
sound or metallic tinkling when the body of the patient is suddenly 
moved or shaken. Changes in position occasion a corresponding 
change in the level of the liquid and the location of the imprisoned air. 
The sounds of the heart acquire a metallic tone through resonance in 
the distended air-chamber of the pericardium, and they sometimes are 
increased to a degree that renders them audible at a distance from the 
patient ; but if the amount of liquid in the heart sac be very consider- 
able, they are generally much reduced. It occasionally happens that 



582 DISEASES OF THE ORGANS OF CIRCULATION. 

friction sounds may also become audible. Somewhat similar sounds 
are sometimes produced in pyopneumothorax, or in extensive pulmonary 
cavities near the heart, or when the stomach contains air ; but under 
such circumstances the ordinary dulness on percussion is persistent in 
the cardiac area. 

The prognosis and treatment of pneumopericardium are exceedingly 
disappointing. Traumatic cases require puncture of the heart sac, and 
the evacuation of its contents through a canula provided with a caout- 
chouc tube whose distal extremity is immersed in a basin of water, to 
prevent admission of air into the heart sac. The trocar should be in- 
troduced through the fifth intercostal space, about one inch from the 
left border of the sternum, where the pericardium lies in immediate 
contact with the thoracic wall. 

Dropsy of the Pericardium. — Hydropericardium. 

The pericardium always contains a small quantity of fluid (liquor 
pericardii). This does not generally exceed one or two drachms. If 
the amount be greater than three or four ounces, it is probably the 
result of disease. Like other dropsical transudations, it is transparent 
and of an amber-yellow or greenish color, occasionally tinged with 
blood to a slight extent. Associated with cancer or tuberculosis of the 
pericardium, or with hemorrhagic diseases, a bloody color may be very 
strongly developed ; under icteric conditions the transudate is bright 
yellow, and contains bile pigment and biliary acids. In chronic cases 
the pericardium may be greatly distended and thinned, and the sub- 
pericardial substance of the heart may exhibit a pale, macerated, and 
degenerated condition. Other morbid changes of the structure of the 
heart are dependent upon the causes of dropsy. 

Hydropericardium is almost always a secondary consequence of 
diseases that interfere with the general circulation of the blood, or that 
produce an impoverishment of that liquid; though it may occasionally 
result from obstruction of the coronary veins through the development 
of cancer, or tuberculosis, or tumors involving the pericardium, or by 
reason of ossification of the coronary arteries. 

The presence of a dropsical transudate in the pericardium may be 
recognized by the same physical signs that have been enumerated in 
connection with pericarditis. The general symptoms are those which 
characterize obstruction of the circulation. 

The prognosis is generally unfavorable. Complete disappearance of 
the transudate may occur, but it is liable to reappear like other 
dropsical accumulations. The treatment must conform to the general 
indications for the management of dropsical symptoms in other parts of 
the body. 

Hsemopericardium. An accumulation of blood in the pericardium 
without previous inflammation is occasionally observed as a consequence 
of wounds or ruptures involving the heart and its bloodvessels, and 
communicating with the pericardial cavity. 



DISEASES OF THE AORTA. 583 

Chylo-pericardium. In very rare instances chyle has also been 
found within the pericardium as a consequence of the formation of a 
channel of communication between a chyle duct and the cavity of the 
heart sac. 



CHAPTEE V. 

DISEASES OF THE AORTA. 

Acute Inflammation of the Aorta — Endaortitis Acuta. 

It occasionally happens that the internal surface of the aorta par- 
ticipates in the processes that occur within the heart, as a consequence 
of ulcerative or verrucose endocarditis. The disease sometimes appears 
to have been preceded by chronic inflammation ; and it is occasionally 
connected with alterations in the cusps of the aortic valve. It must 
not be confounded with the appearances that are produced by post- 
mortem discoloration of the arterial surface with the haemoglobin of the 
blood. Its exciting causes are, for the most part, connected with those 
of the infective diseases, and with Bright's disease, gout, lead poison- 
ing, alcoholism, and cancer. The symptoms of acute inflammation of 
the aorta are so closely connected with those of acute endocarditis that 
a positive diagnosis can scarcely be possible before death. 

Chronic Inflammation of the Aorta — Endaortitis Chronica. 

Pathological Anatomy. Chronic inflammation of the inner coat 
of the aorta causes a development of thickened and indurated patches 
in the intima of the vessel, which produce a roughened and elevated 
appearance of its inner surface. This is most conspicuous in the ascend- 
ing portion and in the arch of the aorta, in those places where the 
blood stream impinges with greatest force upon the arterial wall. 

The thickened patches that have been thus formed sometimes un- 
dergo fatty degeneration, producing what is called atheroma. The 
endothelial surface finally gives way, and the atheromatous mass is 
washed out by the current of the blood. If the patch be very super- 
ficial, a simple abrasion of the surface is the result ; and this may 
become the seat of a thrombus. But when the atheromatous degener- 
ation has extended to a considerable depth, a deep atheromatous ulcer 
is formed, along the borders of which thrombi may become developed. 

Sometimes, instead of these changes, calcification, occasionally ossifi- 
cation, takes place. The extent of calcification may sometimes be so 
great that the entire circumference of the aorta seems to be transformed 
into an unyielding cylinder of mineral matter. Similar processes may 
invade the middle and external coats of the aorta and its branches. 
As a general rule the tendency of such degeneration is greatest at the 



diseases : j :z: ibgaes :y ::rculatic:- 

eD trance of die vessel, and it diminishes as the distance from the aortic 
valve is increased. 

Er::i: -7. Chronic inflammation of the aorta is a disease of old 
ecially common among laboring people and among the vic- 
P syphilis, Bri^i: s I isease. obesity, gout, and diabet— Ejessive 
: : tobacco and alcohol, and poisoning with lead, all tend to favor 
the development of the disease. Since these causes operate more com- 
monly upon the male sex, atheromatous vessels are more frequently 
discovered among men than among women. 

81 ronie inflammation of the aorta may exist to a mod- 

erate extent without producing any recognizable symptoms. Among 
the earliest evidences of its existence may be mentioned the develop- 
ment of a tympanitic character in connection with the diastolic aortic 
sound. Obviously this will not be developed unless the aortic valve is free 
from disease. Sometimes the systolic sound of the heart is accompanied 
by 1 murmur which is conditioned by the abnormal vibrations in the 
aortic walL Sometimes the area of aortic dulness may be slightly 
increased, and pressure with the fingers in the jugular fossa ma; 
cover evidences of induration in the enlarged and inordinately promi- 
nent arch of the vessel Similar changes may sometimes be made out 
in the abdominal aorta. Occasionally the phenomena of thrombosis 
and embolism may be observed to follow the existence of such changes. 
I: s-:-r::*_icS l-izz^^s :'_\: :'..- : 1-7 l : -^.-:.?. ::' -. " • i .: « : -: : zie :• .l- 
nected with the symptoms that have been already detailed, indicating 
an intimate connection between aortic and endocardial diseases. The 
cusps of the aortic valve are most liable to become affected : sometimes 
the curtains of the mitral voire are also involved. In this way the 
symptoms of chronic endocarditis may be sometimes masked, during 
life, by those of valvular disease The connection between dilatation 
ypertrophy of the left ventricle and arterial disease is very evi- 
dent from the fact that, through reduction of the contractile power of 
the aorta, greater effort is needed on the part of the ventricle to effect 
the propulsion of the blood through the arterial system. 



Senile poise. Patient aged seventy-two ; arteries Terr rigid ; considerable hrpertroph j 
of the left ventricle. a >s.) 

The occurrence of atheromatous degeneration and calcification in the 
peripheral arteries affords considerable presumptive evidence of a simi- 
lar condition in the aortic wall. The radial artery at the wrist, and 
the temporal artery afford conspicuous examples of these cha: _ 
through which they become serpentine and rigid, with consequent delay 
in the development of the pulse. The sphygmographic curve exhibits 



DISEASES OF THE AORTA. 585 

retarded development of the ascending limb, with a rounded form of 
the apex and the absence of wave-marks in the descending branch of 
the curve — unmistakable evidences of the loss of elasticity that char- 
acterizes the degenerated arterial coats. (Fig. 121.) 

In extensive arteriosclerosis many of the diseases of old age find 
their origin, either by reason of retarded circulation, or through the 
development of thrombi, or as a consequence of actual rupture of 
the vessels. In this way the symptoms of cerebral anaemia and starva- 
tion, or actual hemorrhage, may arise. Chronic nephritis, cirrhosis 
of the liver, and other kindred diseases, may be developed in the same 
way ; and life is terminated after the appearance of the most various 
symptoms. 

Treatment. The insidious character of the disease prevents the 
possibility of early or specific treatment. Of principal importance is 
the proper regulation of the diet and habits of life. Iodide of potas- 
sium, in five-grain doses, three times a day, has been recommended; 
but, as a general thing, the treatment must be symptomatic and 
directed to the diseases that predispose to the occurrence of endarteritis, 
or to the consequences of its development. 

Aneurism of the Aorta — Aneurysma Aortae. 

An aneurism is a circumscribed dilatation of an arterial duct. Ac- 
cording to their form, aneurisms may be classified as (a) sacculated; 
(b) cylindrical ; (c) spindle-shaped. Aneurisms may be so small that 
they are scarcely visible, as when they occur in the course of the cere- 
bral vessels, or they may reach the dimensions of the skull. 

Aneurisms are said to be axial, when the whole circumference of 
the artery participates in the dilatation ; they are said to be peripheral 
when they are formed by a simple lateral protrusion of the wall upon 
one side only of the artery. 

The cavity of the aneurism generally contains thrombotic layers 
which exhibit an imperfect effort at organization. The cavity is, some- 
times, gradually filled with a fibrinous network that contains colorless 
blood-corpuscles, broken-down red corpuscles, and crystalline masses of 
blood pigment. In this way the aneurismal sac may be obliterated, and 
a sort of spontaneous recovery may be effected. These thrombotic 
deposits occur in all forms of aneurism, but they are most developed in 
the sacculated cases, especially when the orifice of the cavity is con- 
siderably constricted. 

Generally, the three coats of the artery participate in the formation 
of an aneurism; very frequently, however, endarteritis and fatty 
degeneration precede the evolution of the disease, and accomplish their 
results through an enfeebling influence upon the resistance of the 
arterial wall. Atheromatous changes, however, need not always pre- 
cede the growth of an aneurism, since they may occur as secondary or 
associated incidents. It is probable that changes in the middle and 
external coats of the artery which are analogous to the changes that 
occur in myocarditis, may often precede the formation of an aneurism. 
Microscopical investigation indicates the occurrence of atrophy and 



586 diseases ; 7 :hz > b jaws ; - ;ieculatiov. 

nee of the elastic ::;.: previous to th rarance of the 

intinia and of the external : •: if the vessel. With the Yielding of the 
externa] layer rupture must take place, unless the neighboring tis 
by th< a >d serve :: supply the place of the atrophied wall. 

The _ th : rftends the development of an aneurism sonsosta 
chiefly in the progressive riilargement of it- - ^vhich neighboring 

struc: m ressed sc that their function may be impeded or 

The particular character of the disorder thus produced will 
the site of the uieorismal - . and upon t: :»n of 

its growth In this way the lungs may be< and use- 

less, ind the thin the cavity if the thorax may 

le gre tly listurbed. i?-:> ~ and vocal y be thus 

. intc great lisorder. Tiie I Us of the U may also 

experience the effects if pressure, resulting in atrophy and disappear - 
d r :f the upper part ;: the sternum and of portions of the ribs, or of 
the spinal column. After the absorption and removal of these struc- 
tures, the anenrismal tumor remains covered only by the superficial 
tissues and the cutaneous investment of the thorax. E - s soon 
follows, either is consequence if muscular exertion, or through the 
levelopment t alcei ition at the point of greatest pressure, Anenrismal 
ire is not always, however, in the surface of the body, but may 
take place at any point of least resistance, thus effecting a eommunica- 
tion with, and a discharge of its content- into, any of the eavitic 
vascular eh innels within the thorax. Similar a re ob- 

servedwhen the abdominal vessels are the seat if anenrismal dilatation. 
As a sonsec nence if absorption if the lies of the vertebrae, an aneu- 
rism may rupture intc the spinal canal, with consec uencefl that depend 
upon compression or destruction t the spinal cord. 

A rums involve the thoracic portion of the vessel in about 

pei sent if the sases; the fa and its branches furnish 

about '2d per cent. : within the thorax, nearly 60 per cent, of the :■ - 3 

in the as - - . while nearly 30 per 

cent, are seated upon its 

En - r more frequently in the male sex than 

in the female. during the period :: _ 

d the thirtieth and fiftieth years of life. S] s, gout, rheuma- 

alcoholism. c 1 injuries are among the 

non causes of the sure to cold and damp ts - 

predis] singe ise for thf levelopment of the 1 

St:: s. A ist without symptoms : 

but when they have attained any considerable magnitude they 

a 

Exceedingly valuable a .gnostic symptom is the e: of a 

\*a\ If the at t wta is the point of 

igin. the tumor will be die I near the right border of the 

sternum, in the upper intercostal £ I upon the arch of the 

. it will bulge upward into the jugular fossa, and press laterally in 

either direction. A I s - ; aorta lie nearer the 

J column, and exert their pressure between the spine and the left 

<m* of the abd I aorta also make their 



DISEASES OF THE AORTA. 587 

appearance upon the left side of the spinal column. When the tumor 
begins to bulge externally, the skin immediately over it becomes tense 
and shining. As pressure increases, the surface becomes reddened, 
and, finally, falls into a condition of necrosis. The necrotic spot is 
covered by a dry, brown scab, which, at last, separates and is followed 
by an oozing of blood which may increase until complete rupture takes 
place. 

Another valuable symptom is furnished by the pulsation of the 
tumor which can be distinctly felt, and becomes visible as the mass 
protrudes through the thoracic or abdominal wall. So nearly does this 
resemble the cardiac pulsation that, as has been often remarked, it may 
seem as if two hearts were beating in the same breast. 

On palpation the tumor presents a yielding and elastic mass ; the 
characteristic pulsation is perceived as a regular rhythmical movement, 
with alternate contraction and dilatation in every direction, a circum- 
stance that is sufficient to distinguish an aneurismal tumor from other 
growths that may chance to rest upon an arterial trunk. A systolic 
impulse of the heart can be felt, usually, with great distinctness in the 
aneurismal tumor, and it is frequently accompanied by a purring 
fremitus. 

Percussion over the tumor gives evidence of dulness in correspond- 
ence with its extent. When the aneurism lies behind the upper por- 
tion of the sternum the normal resonance is lost, and is replaced by 
dulness on percussion. Similar dulness may reveal the existence of 
unsuspected aneurisms that have presented no other symptoms. Per- 
cussion of an aneurismal tumor in the abdomen may lead to some con- 
fusion, if the tympanitic resonance of the intestines be not sufficiently 
considered. It is well in doubtful cases to secure a thorough evacua- 
tion of the bowels, previous to examination. 

Auscultation yields very different results in different cases. There 
may be distinct systolic sounds or murmurs, diastolic sounds or mur- 
murs, or both ; such murmurs are sometimes audible at a considerable 
distance from the patient. The causes of these variations lie in ex- 
isting differences of form and size of the tumor, and in variations of the 
rapidity of the blood current as it passes through the aneurismal cavity. 
The existence of valvular diseases within the heart may also occasion 
the propagation of morbid sounds as far as the aneurismal tumor, when 
it lies within the thorax, where they may then seem to be originated. 
Through failure of conduction to an unlimited distance from the heart, 
abdominal aneurisms rarely afford any such second sound or murmur. 

It is not unusual for cardiac diseases to be associated with the ex- 
istence of an aneurismal tumor. Aortic insufficiency is frequently 
occasioned by the same chronic inflammatory process that originated 
the aneurismal development. Mitral disease is a less frequent event. 
Hypertrophy and dilatation of the left ventricle are not uncommon as 
a result of the inflammatory action, rather than as a consequence of the 
existence of an aortic aneurism. An uncomplicated aneurism of the 
aorta may actually become the cause of dilatation and atrophy of the 
left ventricle, through pressure upon the pulmonary artery, by which 
the right ventricle becomes enlarged ; while, at the same time, the 



5*S DISEASES OF THE ORGANS OF CIRCULATION. 

left ventricle shrinks in consequence of diminished labor and imperfect 
nutrition, as the health of the patient fails. 

Through the enlargement of a thoracic aneurism, the/-:- t ~ the 

heart may be gradually displaced downward and to the left, if the 
tumor be seated upon the ascending portion or upon the arch of the 
aorta : while it may be crowded toward the right, if the descending 
aorta be involved. 

As the disease progresses the movements of the heart may become 
irregular. Palpitation and dyspnoea may occur, and may be accom- 
panied by severe paroxysms of angina pectoris. Such disturbances are 
not uncommon in certain positions of the body, so that patients are 
compelled to remain in a sitting posture, or to lean forward, or to 
assume various abnormal positions. During periods of excitement the 
cardiac pulsations extend into the carotid arteries The pulse at the 
wrist, beyond the aneurismal tumor, generally lingers behind the car- 
diac impulse, so that an aneurism of the arch, lying between the in- 
nominate artery and the left carotid, occasions delay in the development 
of the arterial pulse upon the left side, while the pulse upon the right 
side remains synchronous with the cardiac beat. The pulsus paradoxus 
(p. 581) is sometimes developed as a consequence of reduction in the 
blood pressure, through the act of inspiration, within an aneurismal 
tumor that communicates with the artery in question. The large veins 
in the neck sometimes exhibit evidence of obstruction and negative pul- 
sation, through compression of the vena? cava?. Collateral paths for the 
return of the blood may become apparent through prominence of the 
cutaneous veins : and the subcutaneous tissues may become actually 
cedematous : while the abdominal viscera suffer the usual consequences 
of retarded blood circulation. 

The pulmonary organs frequently experience great embarrassment 
through compression of the bronchi, or of the lung tissue itself. The 
left bronchus obviously suffers more frequently than the right. Re- 
traction of the intercostal spaces during inspiration may occur through 
impossibility of adequately expanding the lung. Vocal fremitus is 
diminished or entirely absent. Percussion yields a tympanitic reso- 
nance which is transformed into complete dulness if the lung be wholly 
displaced by the aneurismal tumor. Auscultation indicates correspond- 
ing reduction and transformation of the respiratory sounds. Asthmatic 
rusms sometimes occur, which are dependent upon compression and 
irritation of the} istrie ner hes. Sometimes spasm of 

the glottis, vomiting, or cardiac disturbance, may occur through irrita- 
tion of the laryngeal, gastric, or cardiac branches of the nerve. 

Laryng mtation not unfrequently reveals a paralytic 

condition of one or both recurrent nerves. The voice becomes hoarse, 
or reduced to a whisper, and may alternate with a feebly spasmodic 
cough. Complaint is sometimes inade of di __ g sensati ns in the 
throat, as if the larynx were subjected to rhythmic traction in the 
direction of the sternum. 

By reason of pressure up - - >•. difficulty of deglutition 

retimes experienced : examination of the passage with an -esopha- 
geal sound should be performed with great caution, since aneurismal 



DISEASES OF THE AORTA. 589 

tumors have sometimes been ruptured in this way, with immediately 
fatal consequences. Sometimes the difficulty that attends swallowing 
varies with changes in the position of the body. 

One of the most distressing consequences of the development of an 
aneurismal tumor is the occurrence of neuralgia ; this is most frequently 
experienced in the left arm, by reason of the pressure to which the 
brachial plexus is subjected ; a paralytic condition of the limb may be 
produced by such pressure, as the tumor enlarges. Intercostal neu- 
ralgia is associated with aneurisms of the descending aorta ; and, when 
they are developed upon the abdominal aorta, severe pain in the back 
occurs, and the patient becomes bent and bowed through suffering. If 
the spinal column is opened through the effect of pressure, the lower 
extremities and the bladder and rectum become paresthetic and more 
or less completely paralyzed. Insomnia often occurs as a most distress- 
ing consequence of the pain and discomfort that attend the development 
of aneurismal tumors. The vasomotor nerves sometimes exhibit evi- 
dences of irritation or of paralysis in the neck and about the head. The 
pupils are also either dilated or contracted through a similar condition 
of their nervous supply. Some observers have endeavored to trace a 
connection between mental derangement and the existence of carotid 
aneurisms. 

Abdominal aneurisms occasion equally serious disturbances of the 
abdominal viscera ; when located near the diaphragm they may extend 
their influence into the cavity of the thorax through upward enlarge- 
ment or pressure. Gastralgia, paroxysmal vomiting, attacks of colic, 
difficulty of defecation, severe jaundice, hydronephrosis, and other evi- 
dences of compression may be observed according to the site and the 
dimensions of the tumor. 

In addition to the symptoms that may be directly referred to aneu- 
rismal growth and pressure, it is not uncommon to observe a high 
degree of subjective misery ; there is complaint of all manner of pain in 
different parts of the body ; sensations of beating and thumping are ex- 
perienced as if they were originated within the brain ; sometimes such 
symptoms are increased in certain positions of the body. The occur- 
rence of such inexplicable suffering should lead to the suspicion of the 
existence of a latent aneurism. 

The duration of the disease is exceedingly variable ; the average 
period after the discovery of a tumor is from fifteen to eighteen 
months. 

Recovery seldom occurs. Death may occur through the develop- 
ment of a cachexia, such as is sometimes observed as a consequence of 
valvular disease of the heart. Hemorrhages take place from the 
mucous membranes, and death is preceded by oedema and marasmus. 
In other cases compression of the oesophagus may occasion slow starva- 
tion ; again, death may result from axphyxia, occasioned by compres- 
sion of the lungs or respiratory passages ; intercurrent inflammations, 
paralysis, or embolic process in the brain or peripheral arteries, may 
lead to a fatal termination. 

Death very often results from the rupture of an aneurismal tumor. 
This may occur externally or into neighboring cavities within the body, 



." .■ ' iiszASZsoriEi r l a tios 

with the symptoms of internal hemorrhage and d: stent a of the af: 

| ericardium or pleura. The estahni f an opening 

betwc t _ _ :_ : will be indi- 

cate<I of blood from the bronchi or trachea, or 

eructation from the oesophagus. Vomiting or | _ . if blood. 

pearance in the urine, indicate a communic;: the si mach 

t :u:es::: - _t~ 

3E rhe diagnosis has I sets the recognition :: the 

existence :: : he aneurism, and also the determination of its locality. 

The : » of ] nljsn : -._- laryngeal muscles, :r difficult 

_ md severe neuralg: : issoc ■_ cir- 

scribed murmurs in the mise fthe aorta which cannot be other- 

wise :: inc . should lead to the b ds icion of latent ane: is as 

If a pulsating tumoi be ^ must be 7 :ed from 

• " " - ; - . ■" -. . " - '. - : eferen :-e :<: the :h 1 . stci : : 

the pulsation, which is uniform- 7 leveJoped in every direction in the 
case of an eurismal enlargement, while a solid tnmoi sin - and 

falls in a direction at right angles with the use : the upon 

which it lies 

Haying 7.7: mimed the existence of an aneurism, its location mcr 
inferred by its prominence neai the right lordet >i :_r s:ernum in the 
second and third intercostal spaces, when .: : ; connected ^rith the 
attending aorta. If : igi n i ting in the innominate artery, i t proj ec ts 
upward and outward under the right Aneurisr irch 

- t lecupy the sj ice behind the per portion of the sternum 

or along its left border ; aneurisms descending aorta are most 

:.:__ .._/■ :::_t level : s thoracic ver- 

tebra : while aneurism i - ' ■'■ : ~ ta be easily 1m 

if the abdominal waDfi are suffi elding and unincum 

w::i -■?.-.. 

Pkoghosbs. Aortic inenxisnie u:-rd a very unfa- _ _»sis. 

Spontaneous recovery rarely ocean, and the effects : treatment are not 
encouragi: ig 

_ : rhe .rdinary rules that have been previously laid 
.reatmen: : ..irdiac disc be obse: 

Pain ism sf a 7 the hypoder._ f morphine: pal- 

n and c th ice and 

with digitalis : imr ssthe administration 

of iron, quinine, and ferrated mineral waters. I elop- 

: e tumor may call for applications of : and for sup- 

porting apparatus in the form of well-adjusted bai _ - 

Iodide of potassium grains :»m- 

mended, especially in cases that are dependent upon syphilitic infection. 
at extent I y hypo- 

dermic injection of ergotine has its advoca: a 

coagulation of the blood within an aneurismal 
cavitv have been frequently attempted : for this purpose the liquor 
ferri perchloridi has been injected into t: ty of an aneurism, but 

rery dangf - .eriment in Done sk of pro- 

ducing embolic obstruction of peripheral arteries with fragments of the 



DISEASES OF THE AORTA. 591 

clot that are thus formed. Other experimenters have attempted the 
introduction of fine wire, slender watch springs, floss silk, and other 
similar substances, with a view to the coagulation of the blood as it is 
brought into contact with these foreign bodies. Less hazardous, per- 
haps, is the employment of the constant current by the introduction of 
a long, slender needle into the cavity of the tumor, which is thus 
brought into connection with the anode of a battery containing eight 
large elements, while the cathode is in communication with an indiffer- 
ent portion of the body outside of the tumor ; the needle must be 
insulated throughout the greater portion of its length, so as to avoid a 
caustic effect upon the thoracic wall ; the current should not be passed 
through the tumor for more than an hour. Coagulation takes place 
around the uninsulated portion of the needle ; and upon the clot thus 
formed, additional precipitation of fibrin may occur. The operation 
may be repeated after a few days, if necessary. 

The treatment of subclavian and other aneurisms by ligature de- 
mands surgical interference, regarding which full particulars are con- 
tained in the text-books on surgery. 

Constriction and Occlusion of the Isthmus of the Aorta. 

That portion of the aorta between the region of the left subclavian 
artery and the commencement of the descending aorta constitutes the 
isthmus. During foetal life this portion of the vessel is abnormally 
constricted, and it occasionally happens that such constriction persists 
after birth. Sometimes the calibre of the aorta becomes so reduced 
that it will admit the passage of nothing larger than a bristle ; again, 
it may be completely occluded. The left ventricle of the heart is fre- 
quently dilated and hypertrophied, and the endocardium may exhibit 
consequences of chronic inflammation. The ascending portion of the 
arch of the aorta becomes dilated as a consequence of the obstruction, 
and it may exhibit evidences of endarteritis. The blood is compelled 
to find collateral channels for its circulation, and, consequently, all the 
branches of the left subclavian artery become enlarged. The branches 
of the internal mammary, transversa colli, and transversa scapulae 
arteries, through their communications with the intercostal arteries, 
furnish a passage for the blood into the descending aorta within the 
thorax ; while the lower branches of the mammary artery afford a com- 
munication by way of the superior and inferior epigastric arteries with 
the iliac vessels. The enlarged vessels become serpentine, and pulsate 
distinctly. The degree of constriction in the isthmus of the aorta may, 
with considerable accuracy, be inferred from the amount of development 
exhibited by the collateral circulation. 

The pulsations in the abdominal aorta, and in the crural artery, are 
considerably retarded in comparison with the cardiac impulse, and the 
current of blood through those vessels is usually much diminished. 
The left ventricle becomes dilated and hypertrophied in about one-half 
of the cases. 

It often happens that the defect is only discovered after death. In 
other cases the usual consequences of cardiac overwork are manifested 



DISEASES OF THE ORGANS OF CIRCULATION. 

— . v.. palpitation, subjective dyspnoea, cough, haemoptysis, di 
and the other consequence- • icted circulation. Death sometimes 

is caused by cerebral hemorrhage, or by rupture of the heart, or - 
consequence of cardiac paralysis after violent muscular exertion. In- 
tercurrent diseases may also terminate life, which is sometimes greatly 
prolonged in spite of the defect, in one case reaching to the ninety- 
second year. 

Congenital Narrowness of the Entire Aorta. 

By reason of defective nutrition during fcetal and early life, it some- 
times happens that the aorta never reaches its normal development, but 
always retains infantile dimensions. Under such circumstances its 
walls are excessively thin and yielding. The changes that are pro- 
duced by chronic inflammation are not uncommon in it- is. The 
defect is usually observed among chlorotic patients, and is associ 
often with defective development of the sexual organs. Dilatation and 
hypertrophy of the heart, with the usual consequences, are not 
uncommon. 

Rupture of the Aorta. 

The aorta may be penetrated by wounds and injuries, but its spon- 
taneous rupture is dependent upon previous disease affecting its walls — 
e. <7 . endarteritis, and fatty degeneration. It often occurs as a conse- 
quence of aneurismal dilatation ; again, it may be observed as a conse- 
quence of ulcerative processes in the neighborhood of the vessel, such 
is scar in caries of the vertebrae, cancer of the oesophagus, or ulcera- 
tion of that passage subsequently to its injury by swallowing foreign 
bodies that become lodged in its course, or produce laceration of its 
walls. 

Complete rupture of the arterial wall produces speedy death from 
hemorrhage : but. sometimes, the rent does not extend through the 
whole thickness of the aortic wall, but may involve only the inner coat : 
the blood then finds its way between the outer coats and the middle and 
internal layer, producing what is called a dissecting - / the 

aorta. In this way blood may find its way between the layers of the 
arterial wall as far as the peripheral arteries. A dissecting aneurism 
has been known to extend from the entrance of the aorta as low as the 
popliteal artery. Complete rupture usually follows after a time, though 

a - -f recovery have been known. 

The occurrence of aortic rupture is sometimes indicated by sudden, 
severe pain, as if something had given way within the body : this is 
followed by great anxiety, rapid anaemia, and speedy loss of strength — 
symptoms which indicate internal hemorrhage. Death may occur 
almost instantaneously, or only after several days. Longer duration of 
the condition is very rare. 

Embolism of the Aorta — Embolia Aortae. 

A tisnw are very rare. They sometimes occur as a conse- 

quence of endocardia] thrombi which break loose and obstruct the 



DISEASES OF THE AOETA. 593 

aorta, or they may be produced by tumors, or by echinococci, which 
have found entrance into the left ventricle. Aneurismal clots some- 
times enter the circulation, and obstruct its course through the descend- 
ing aorta. Similar results have been known to follow childbirth, or 
infective diseases. 

Symptoms. The symptoms depend upon the level of the obstruction. 
Sudden death follows occlusion of the upper portion of the aorta. 
More frequently the obstruction takes place at, or near, the bifurcation 
of the abdominal aorta ; this produces obstruction of the circulation in 
one or both of the iliac vessels ; its occurrence is frequently indicated 
by a sensation of severe pain in the lower part of the abdomen or in the 
extremities ; the lower limbs become cold, stiff, and enfeebled ; various 
disorders of sensation are experienced in the affected parts ; the skin 
feels cold and is either pale or livid ; the arterial pulse cannot be felt 
beyond the seat of obstruction ; sensibility and the power of motion in 
the affected limbs is greatly reduced or entirely abolished. If a collat- 
eral circulation can be established, the symptoms gradually subside ; 
but, sometimes, they are renewed or transferred to other portions of the 
body. It often happens that the embolism in one of the arteries of the 
lower limbs may become the starting-point of a thrombus which may 
extend upward even as far as the iliac trunk. Complete obstruction of 
the circulation is followed by dark discoloration of the skin, with the 
development of dry and moist gangrene in the extremities. Death 
occurs as a consequence of exhaustion or of septicaemia. Embolism of 
the thoracic or abdominal portion of the aorta is attended by the above- 
described symptoms, and also by evidences of spinal anaemia, among 
which paralysis of the bladder and rectum are conspicuous. Occlusion 
of the gastro-intestinal and renal arteries may be followed by vomiting 
and purging of blood, and by the presence of blood in the urine. 

Prognosis and Treatment. The prognosis is very unfavorable. 
The treatment must be purely symptomatic. 

Thrombosis of the Aorta — Thrombosis Aortae. 

As a consequence of arterio-sclerosis small and insignificant thrombi 
are not unfrequently observed upon the inner lining of the aorta. 
They are almost universally observed in cases of aortic aneurisms, and 
they sometimes extend from the cavities of the heart into the aorta. 
Aortic embolism sometimes produces extensive thrombosis, and the 
same thing may be produced by compression of the arterial wall. 
Under such circumstances they are more commonly observed in the 
abdominal aorta than in the thoracic, because of the greater force of 
the circulation in the upper portion of the vessel. The symptoms vary 
according to the magnitude and the location of the thrombus. Con- 
siderable obstruction of the aorta may lead to the development of 
symptoms which indicate obstruction of the circulation ; and complete 
occlusion of the upper part of the vessel is followed by speedy death. 

38 



PART VII. 

DISEASES OF THE BLOOD. 



CHAPTER I. 

DISEASES OF THE BLOOD. 

Leukaemia. 

Etiology. Leukcemia is a disease that is characterized by a pro- 
gressive increase in the number of white blood -corpuscles, while the 
number of red corpuscles is steadily diminished. 

Three forms of leukaemia are usually described : the splenic variety, 
in which the origin of the disease is supposed to be located in the 
spleen ; the lymphatic, and the myelogenous varieties, in which the 
lymph glands and the marrow of the bones are respectively implicated. 
As a matter of fact, however, these forms of the disease are usually 
associated. Sometimes one set of organs, sometimes another, is 
chiefly affected. The splenic form is most commonly observed ; and 
with this is frequently associated the lymphatic variety. It is probable 
that the osseous marrow is involved more frequently than has been 
stated, since its examination is attended with greater difficulty than the 
investigation of the other organs of the body. 

Leukaemia is observed about twice as often among men as among 
women. It usually occurs between the twentieth and fiftieth years of 
life, though it has been described among children and among old people. 
It is among the poorer classes of society that it most frequently exists, 
and it seems to be more prevalent in certain countries and localities 
than in others. Hunger, cold, and squalor appear to favor its develop- 
ment. It has sometimes followed injuries of the spleen or of the bones. 
Violent exertion and mental stress favor the development of the 
disease. Among the female sex, the incidents of pregnancy, parturi- 
tion, etc., are not without unfavorable influence. It has been noted as 
a result of chronic diarrhoea, and of cachetic conditions following 
various infective diseases, especially after malarial poisoning. Rickets 
may be mentioned as a predisposing cause, and sometimes pseudo- 
leukcemia becomes merged in the full-fledged disease. 

Symptoms. The cardinal symptom of leukcemia is the change in 
number of the corpuscular elements of the blood. The microscope 
readily reveals the presence of an excessive number of white blood- 



596 



DISEASES OF THE BLOOD. 



corpuscles. Instead of one colorless corpuscle to every 350 or 500 red 
corpuscles, their respective numbers are sometimes equal ; and occasion- 
ally the white corpuscles are in a majority. (Fig. 122). Under such 
circumstances the blood appears thin and pale, occasionally so greatly 
altered in its constitution that it looks more like dirty water than like 
healthy blood. Xot only is the number of the white corpuscles greatly 
increased, but that of the red corpuscles is also largely diminished. 
Instead of containing 5,000,000 of corpuscles, the cubic millimetre 

Fig. 122. 




Drop of blood from a case of splenic and lymphatic leukaemia. There is great excess 
of the white corpuscles; these are seen to be of various sizes. (Drawn from an actual 
" field" by Dr. John Wilsox. 



may contain less than one-tenth of that number, in severe cases of the 
disease. The red corpuscles are variable in their size, and frequently 
present irregular deformities, constituting what is known as poikil<>- 
cytosis. 

The specific gravity of the blood is considerably diminished, and its 
coagulability is reduced. When drawn from the veins it clots loosely, 
with a layer of white corpuscles forming a pallid surface upon the 
external portions of the coagulum. The amount of haemoglobin in the 
blood is necessarily diminished by the reduction in the number of the 
red corpuscles. It is sometimes, though not always, diminished below 
the normal standard in the individual corpuscles themselves. 

The spleen is almost always greatly enlarged. It is sometimes sensi- 






DISEASES OF THE BLOOD. 597 

tive to pressure, and its capsule may be roughened by peritoneal 
inflammation, so that a friction sound is audible when the abdominal 
wall and the tumor undergo relative displacement by pressure or other- 
wise. Rupture of the spleen has been known to occur as a consequence 
of its enormous distention. 

The lymph glands are often greatly enlarged, and become prominent 
under the skin, especially in the neck, in the axillae and groins These 
enlarged glands are not sensitive to pressure, and they are not adherent 
to one another or to the skin. Unlike the enlarged glands in tuber- 
culosis, they rarely exhibit any evidence of inflammation, caseation, or 
suppuration. In many instances the spleen and lymph glands undergo 
enlargement a considerable time before the manifestation of pathologi- 
cal changes in the blood. The lymphatic glands within the thorax and 
the abdominal cavity also manifest a similar tendency to increase in 
size. Compression of the trachea and bronchi may thus be originated, 
interfering considerably with the act of respiration. Compression of the 
pneumogastric nerve may disturb the action of the heart, and may pro- 
duce paralysis of the laryngeal muscles. Within the abdominal cavity 
the enlarged mesenteric glands may be recognized in the form of mul- 
tiple tumors. The adenoid tissue in the tonsils, and about the root of 
the tongue, and in the pharynx, sometimes becomes swollen. The 
thymus and thyroid glands may participate in the general process of 
glandular disease. 

When the marrow of the bones becomes involved it is sometimes indi- 
cated by pain, especially in the sternum and spinal column. Sometimes 
the long bones also exhibit a similar condition. 

The amount of uric acid in the urine is considerably increased, some- 
times reaching an amount that is six or seven times greater than the 
normal quantity. The phosphates and sulphates are also increased, 
but the urea does not exhibit any decided change until the progress of 
cachexia determines its reduction. 

In about one-fourth of the cases of leukaemia the retina exhibits 
characteristic changes. It is usually pale and yellow ; the veins are 
enlarged and tortuous, and of a lighter color than in the healthy eye ; 
the arteries are contracted ; sometimes hemorrhages into the retina are 
visible, and yellow spots, surrounded by extravasated blood, become 
prominent ; when the lesions approach the macula lutea, eyesight is 
somewhat affected, and thus attention may be directed to the disease. 

The sense of hearing is sometimes affected by the development of 
lymphoid tissue in the labyrinth. Hemorrhages in the cochlea some- 
times produce sudden deafness. 

Occasionally lymphoid indurations exist in the skin. 

Among the earliest symptoms of the disease are increasing pallor 
and diminished vigor. Sometimes pain is experienced in the region of 
the spleen. The subcutaneous layer of fat is often retained until a late 
period of the disease. Copious perspiration is not uncommon, especi- 
ally in the form of night-sweats. An oedematous condition of the skin 
is often observed, and a tendency to boils and pustulous eruptions is 
not uncommon. The temperature is sometimes elevated, but presents 
no uniform or regular increase. The pulse is generally weak and 



59$ DISEASES OF THE BLOOD. 

rapid. As a consequence of the diminution of the number of red blood- 
corpuscles there is frequent complaint of breathlessness. Sometimes 
actual dyspnoea is produced through compression of the respiratory 
passages by enlarged lymph glands. Catarrhal inflammations of the 
respiratory organs are not uncommon, and sometimes result fatally. 
The heart is frequently dilated, and may be displaced by an enlarged 
spleen. Anaemic murmurs are also audible. 

The cavity of the mouth and pharynx are not frequently inflamed. 
The appetite disappears, but thirst is increased. Sometimes fatal 
hemorrhage from the fauces or other portions of the oral cavity may 
occur. The usual symptoms of indigestion are furnished by the 
stomach and intestinal canal. Sometimes obstinate diarrhoea terminates 
the life of the patient. The liver is usually enlarged, and sometimes 
ascites is developed. 

A tendency to uncontrollable hemorrhage is a characteristic symptom 
of leukaemia. It may occur from any portion of the mucous membrane 
of the body, or into any of the organs and tissues. 

The intellectual faculties remain undisturbed until the close of life, 
but the delirium and mental derangement that accompany exhaustion 
are not uncommon events. 

Leukaemia is a disease that usually persists for one or two years, 
though cases are described in which it has continued for eight years. 
Occasionally, however, an acute form of the disease may develop and 
complete its course to a fatal result in the space of three or four weeks. 
These cases are sometimes accompanied by a febrile movement that 
subsides into a typhoid condition. Death usually results from pro- 
gressive exhaustion, though it may be caused by various complications 
of the disease. 

Pathological Anatomy. The principal pathological changes are 
exhibited in the blood and in the organs which elaborate the constitu- 
ents of the blood. The adenoid tissue becomes greatly increased 
throughout the body, wherever it is normally situated, and in many 
localities where it intrudes itself into other tissues. The neoplastic 
substance may exist as a diifuse infiltration, or it may be circumscribed 
in the form of minute indurations that closely resemble tubercL. - 
miliarv carcinoma. The tubercular bacillus is. however, always absent, 
and the little tumors do not undergo caseation. 

The lymph glands become greatly enlarged. At first they are soft, 
but become gradually indurated by the increase of connective tissue. 
The tracheal and bronchial glands, with the thyroid and thymus 
glands, become enormously increased in size. The whole length of the 
respiratory tract is frequently beset with adenoid masses that encroach 
upon the respiratory tract. A similar condition is exhibited by the 
adenoid tissues of the stomach and intestines. Sometimes the lymph 
follicles and patches of Peyer are in a condition that reminds one of 
the effects of typhoid fever. In the serous cavities of the pericardium, 
pleurae, and peritoneum, there is frequently an abundant transudate, 
which is sometimes tinged with blood. The heart is pale and flaccid ; 
the right ventricle sometimes contains blood which so nearly resembles 
pus that it suggests the idea of an abscess. The spleen is often im- 



DISEASES OF THE BLOOD. 599 

mensely enlarged, sometimes weighing twelve to fifteen pounds. Its 
peritoneal capsule is often inflamed and adherent to the neighboring 
surfaces. When its connective tissue is greatly increased, the organ is 
considerably indurated, but it is soft when the principal change in- 
volves a proliferation of the cells of the splenic pulp. Sometimes the 
splenic follicles are greatly enlarged ; hemorrhagic infarcts and great 
accumulations of pigment have been noted, especially after malarial 
infection. 

The liver is usually very much enlarged, through the increase of 
adenoid tissue which fills its interstices and frequently produces atrophy 
of the parenchyma. The hepatic capillaries are often obstructed with 
colorless corpuscles, and their walls are infiltrated with leucocytes. A 
similar condition exists in the pancreas. 

The kidneys are more or less infiltrated with adenoid tissue, espe- 
cially in the cortical portions of the organs. Leucocytes are very 
numerous in the neighborhood of the capillary bloodvessels. Occasion- 
ally amyloid degeneration of the kidney occurs. The supra-renal cap- 
sules are sometimes so greatly distended by the development of adenoid 
tissue that they are actually ruptured. Similar infiltration of the brain 
and of its membranes sometimes exists. Hemorrhage is not uncom- 
mon. The tendency to hemorrhage, infiltration, and degeneration in 
the retina has been already noted. 

The marrow of the bones exhibits changes both in the spongy and 
in the tubular bones. The fat cells disappear and are replaced by 
hemorrhagic extravasations and adenoid infiltrations. The substance 
of the bone itself generally becomes rarefied and spongy. 

Diagnosis and Prognosis. The disease may be easily recognized 
by the aid of the microscope. From the transient leucocytosis that 
accompanies pregnancy, marasmus, and infective diseases, leukaemia 
may be easily distinguished by the greater increase of colorless cor- 
puscles, and by its persistent and fatal course. 

The prognosis is most unfavorable, since recovery scarcely ever 
occurs. 

Treatment. Since the disease is often excited by previous experi- 
ence of an infective disease or injury of the bones or spleen, it is desir- 
able that all such ailments should be efficiently treated, in order to 
prevent so unfortunate a sequel. When leukaemia is actually recog- 
nized, general hygienic measures must be carefully employed. Iron, qui- 
nine, strychnine, and cod-liver oil are useful agents for the promotion 
of healthy nutrition. Phosphorus and arsenic sometimes afford good 
results, but in the vast majority of cases whatever relief is obtained can 
be only temporary in its duration. The inhalation of oxygen, trans- 
fusion of blood, injection of ergotine, arsenic and other drugs into the 
spleen itself, and the application of electricity, have all been attempted 
without any satisfactory result. The spleen itself has been removed, 
but with an almost invariably fatal termination. 

Pseudo-leukaemia. 

This disease (Hodgkin's disease of the English, Adenie of the French) 
closely resembles leukaemia in the majority of its symptoms and in its 






DISEASES OF THE BLOOD 



clinical development, bur differs from it in the fact that the oolc 
corpuscles of the blood are not increased in number, and that the uric 
acid in the urine exhibits no increase in quantity. 

Etiology. Pseudo-leukemia is frequently due to the same causes 
that produce or excite leukaemia, but in many instances it is developed 
without any discoverable cause. The disease is more frequent among 
men than among women : it may occur at all ages, but is most com- 
monly observed during early adult life, or in old a^e. 

Pathological Anatomy. The pathological changes that occur dur- 
ing the course of pseudo-leukcemza are identical with those which have 
been already described in connection with leukaemia. Only in the 
blood does a difference exist. The enlarged lymph glands are at first 
soft and yielding, but they become indurated by reason of the growth 
of connective tissue. Caseation, suppuration, and amyloid degenera- 
tion may occasionally involve the enlarged glands. 

The points of resemblance between pseudo-leuktemia and leukaemia 
are so numerous that many pathologists incline to the belief that they 
are merely varieties of the same disease. The normal condition of the 
white blood-corpuscles has been ascribed to obstructive changes in the 
lymph glands by which the escape of leucocytes or lymph corpuscles 
and their entrance into the blood have been prevented. 

Symptoms. Pseudo-leukaemia may exist in three principal forms : 
the splenic, the lymphatic, and the myelogenic. In the splenic form 
the spleen is greatly enlarged : the patient becomes very anaemic : the 
red corpuscles are greatly diminished in number, and exhibit deformity 
and reduction in size. The amount of haemoglobin is somewhat leas 
than one-half of the normal quantity : the urine exhibits no marked 
change. 



Fig 




Pseudo-leukaemia. (Rush Medical College 



In the lymphatic form of the disease the lymph glands are generally 
enlarged. The process begins in the glands of the neck, and extends 
to all the lymph glands of the body. The enlarged glands under the 



DISEASES OF THE BLOOD. 601 

jaw can be distinctly felt under the skin, sometimes extending in a 
chain to the clavicle, or forming a hideous collar around the whole cir- 
cumference of the neck ; they are somewhat movable and separate from 
one another, like grapes in a cluster. (Fig. 123.) In the earlier 
stages of growth the glandular enlargements are soft, and frequently 
exhibit rapid variations in size. 

The myelogenic form of pseudo-leukaemia is very rare, and very little 
is known regarding its nature. 

The disease is usually very tedious in its course, lasting for a num- 
ber of years, though it is usually less chronic than leukaemia. The 
process of glandular enlargment is frequently accompanied by fever, 
especially when a new cluster of glands is invaded. In acute cases 
involving the spleen and internal lymph glands, the symptoms may be 
sometimes mistaken for those of typhoid fever. 

The consequences of glandular enlargement in pseudo-leukaemia are 
identical with those which have been already described in leukaemia. 

The tendency to cutaneous eruptions and lymphoma is also similar 
in the two diseases. Occasionally the skin becomes pigmented in a 
manner similar to what is observed in Addison's disease. A gradual 
transition to the development of complete leukaemia is not an uncom- 
mon event. 

Diagnosis and Prognosis. The disease may be easily recognized 
and differentiated from leukaemia by the aid of the microscope. The 
prognosis is identical in the two diseases. 

Treatment. The same measures that are useful in the management 
of leukaemia should be adopted for the treatment of pseudo-leukaemia. 
The most successful form of internal medication consists in the 
administration of arsenic, and in the injection of Fowler's solution into 
the substance of the enlarged lymph glands. By this method cure of 
the disease has been occasionally reached. The removal of enlarged 
glands by surgical interference is scarcely practicable, since it is impos- 
sible to reach any but the most external tumors. Lately the use of 
green soap has been recommended ; it should be dissolved in warm 
water, and rubbed into the back and limbs for twenty minutes twice a 
week. Electricians have reported favorable results from the applica- 
tion of strong faradic currents to the enlarged lymph glands, but in 
the majority of cases all forms of treatment meet with equal discourage- 
ment. 

Progressive Pernicious Anaemia — Anaemia Progressiva Perniciosa. 

Etiology. Pernicious anosmia is characterized by a progressive 
and almost invariably fatal impoverishment of the blood. The disease 
may be of primary origin when it occurs without apparent cause, 
or it may be the secondary consequence of mental and physical over- 
exertion, or of other morbid causes. Residence in unwholesome quarters, 
occupation in ill-veutilated and unhealthy factories, and insufficient 
diet have been assigned as causes of the disease. It sometimes occurs 
during the course of pregnancy, or after parturition, and it may follow 
chronic diarrhoea or other diseases that are accompanied by wasting 
discharges. 



602 • DISEASES OF THE BLOOD. 

The geographical distribution of the disease exhibits considerable 
variations which are probably dependent upon the social condition of 
the population. With the exception of those cases which depend upon 
pregnancy and childbirth, the disease occurs with equal frequency 
among males and females. It is most commonly observed during adult 
life. 

Symptoms. The majority of the symptoms of pernicious ancemia 
are dependent upon impoverishment of the blood. The disease ordinarily 
commences in an insidious manner, indicated by excessive fatigue after 
slight exertion, copious perspiration, and shortness of breath. Palpi- 
tation of the heart, faintness, and dizziness are not uncommon ; the 
patient becomes paler and weaker until he can no longer remain upon 
his feet. Sometimes the skin exhibits a peculiar gray or brownish 
color, and the whites of the eyes present a slightly yellowish tinge. 
Perspiration ceases, and the surface of the body becomes dry and 
scurfy ; the hair loses its glossy smoothness, and frequently falls out ; 
the nails become thickened and brittle ; in many instances subcutane- 
ous hemorrhages occur ; these are most abundantly distributed over the 
lower extremities, though visible elsewhere, and upon the surface of the 
mucous membrane of the mouth, and into the internal organs of the 
body ; not unfrequently the face and hands become oedematous ; chem- 
osis is sometimes developed ; the serous cavities are also occupied by a 
moderate amount of transuded liquid which may be slightly tinged with 
blood pigment ; the subcutaneous layer of fat is usually, though not 
always, well developed ; the muscles are ordinarily flaccid, and some- 
times sensitive to pressure ; in like manner the bones, for example the 
sternum, are occasionally sensitive to pressure ; the respiratory organs, 
in uncomplicated cases, exhibit no characteristic disorders, aside from 
the dyspnoea that is occasioned by a deficiency of red blood-corpuscles ; 
palpitation of the heart is not uncommon ; the pulse is usually weak 
and rapid ; sometimes dilatation of the heart may be discovered ; 
anaemic murmurs are audible over the cardiac area and along the course 
of the large arteries and veins ; the bodily temperature frequently re- 
mains normal, but sometimes it is considerably elevated ; this febrile 
movement exhibits no regularity, and is frequently paroxysmal, con- 
stituting the characteristic fever of ansemia ; the intellectual faculties 
often remain unchanged throughout the course of the disease, but in 
many instances the patient lies in a condition of semi-consciousness, 
exhibiting a sluggishness and torpor from which he is with difficulty 
aroused ; sometimes, however, delirium and maniacal excitement are 
manifested as a consequence of the ill-nourished and unstable condition 
of the brain ; insomnia is a very common symptom, and the night-time 
is often particularly disturbed by the restlessness of the patient, who 
remains all day in a slumberous condition. 

Jlicroscopical examination of the blood shows that its elements are 
greatly reduced in number. In one case the red corpuscles numbered only 
143,000, instead of 4 or 5,000,000, in the cubic millimetre. The sur- 
viving red blood-corpuscles are often considerably enlarged or diminished 
in size, and exhibit various deformities (poikilocytosis). The amount 
of haemoglobin is greatly reduced in its aggregate, though it may be 



DISEASES OF THE BLOOD. 603 

actually increased in the individual corpuscles. The proportion of iron 
is also less than half the normal quantity. 

The alimentary canal exhibits notable disorders. Hemorrhage and 
ulceration within the cavity of the mouth are not uncommon. The 
breath is usually very offensive. Appetite is generally lacking, but 
sometimes the opposite condition of hunger and thirst exists. The 
stomach is often sensitive to pressure, and exhibits all the symptoms of 
chronic indigestion. Sometimes there is vomiting, and blood may 
accompany the discharges ; in such cases bloody diarrhoea is not un- 
common. The spleen is frequently enlarged. The urine varies in 
quantity and in quality ; occasionally it contains blood and traces of 
albumin, but there is no uniformity in the changes that are observed in 
connection with the urinary secretion. 

Transient disturbances of the peripheral nerves are sometimes ob- 
served ; these assume a paretic, spasmodic, or a paresthetic character. 
Sometimes the patellar reflex is absent. Sudden deafness, blindness, 
or loss of other special senses, sometimes occur. These accidents may 
be of a purely functional character, and transient in their duration, or 
they may result from actual hemorrhage. Retinal hemorrhages are 
frequently present, though they do not necessarily occasion loss of sight. 
Occasionally the retina becomes cedematous, and the phenomena of 
choked disk are developed. 

The progress of pernicious anaemia is sometimes very rapid. The 
disease may complete its course in a few weeks, or it may linger for 
several months, or even longer. Sometimes alternate remissions and 
exacerbations follow one another, but in the majority of cases a fatal 
termination is reached at last. Death sometimes occurs as a conse- 
quence of gradual exhaustion ; in other cases it is preceded by con- 
siderable elevation of the temperature ; but sometimes an excessive 
depression of the temperature is observed. Death is often preceded by 
a copious perspiration that exhales a cadaveric odor. 

Sometimes pernicious anaemia develops the symptoms of leukcemia, 
or it may be associated with sarcomatous or carcinomatous growths in 
different parts of the body. 

Pathological Anatomy. The most characteristic changes that are 
produced by progressive pernicious anaemia are capillary hemorrhages, 
which may occur only in the organs and tissues of the body ; fatty 
degeneration caused by imperfect oxidation ; and general impoverish- 
ment of the blood. The amount of subcutaneous fat is increased, and 
it is rarely diminished in the internal organs. A small amount of 
serum is usually present in the serous cavities ; it may be either clear 
or tinged with blood, or of a yellowish color, even though no signs of 
jaundice be present. The heart is usually empty, flaccid, and small, 
though sometimes it is enlarged and dilated ; in many cases its muscu- 
lar substance appears streaked or spotted with yellowish masses which 
the microscope exhibits in a condition of fatty degeneration. The 
valves of the heart remain unchanged, notwithstanding the endocardial 
murmurs that are audible during life. The large bloodvessels are 
usually in a normal condition, though sometimes they are atheromatous. 
With the exception of interstitial hemorrhages, the lungs present little 



i-iseasis ; j :hz -:;:, 

departure from health. The general tendency to oedema is sometimes 
manifested by an oedema of the lott t. The and the liver are 

frequently enlarged. The ie :ften distended with dark- 

colored bile. The ~ ire sometimes _ fat. and 

the org stains an excessive amount of iron, apparently derived from 

the destruction of the red corpuscles of the blood. The spleen 
contains a - _ excess : iron. The mucous membrane of thr >\ 

i is edematous, and exhibits numerous capillary hemor- 
rhages. The":. follicles are diste .-.-"". 
free nently exhibit fatty degeneration of the glandular epithelium, and 
so sequent atrophy, which must not be mistaken for the primary cause 
of the lisease. The -:-. ieru is are >ften enlarged, and the . 
ereas presents considerable swelling, together with interstitial hemor- 
_rs and fatty degeneration of its glandular epithelium. Essentially 
the same condition exists in the substance of the brain and of the * 

The a :: the sympathetic nerve exhibit numerous evidences 

: catty legeneration of the nerve fibres and ganglionic cells, together 

with proliferation of the nnectrfe tissue. The peripheral nerve* escape 

without characteristic changes. Tie condition :: the 'etima has been 

_ 

lescribed. The marrow oj -\ es is frequently unchanged, but 

sometimes it is the seat of interstitial hemorrhage, and the fat cells 
become atrophied and replaced by red lymph-cells like those which 
mstitate the red marrow in the sj jngy t >nes, 
Theesgt - - of progressive pernicious anaemia remains unex- 

plained. The majority of the pathological changes and symptoms are 
dependent upon impoverishment of the blood, but the cause of that 
impoverishment is not yet understood. It has been assumed that the 
— — ~ in some way connected with the blood-making organs, notably 
with the marrow of the bones, which furnish to the blood imperfectly 
developed elements that undergo rapid destruction in the liver and 
spleen. The lack of uniformity in the condition of the osseous marrow 
is. however, an obstacle to the acceptance of the opinion that these 
changes are anything more than the secondar; - a : the 

se ::self. 
DlAGH SIB. It is not so easy tc differentiate progressive pernicious 
anaemia in the early stage of the disease. Incipient 

may _ se to almost identical symptoms 

regis can usually be distinguished by the fact that it is seas which 
almost invariably exists in the female sex. and is _ 

of puberty ; it is also free from fever, and usually recovers under 
is Treatment. In localities where exists the mtesi 

im duodenale, it is necessary to remember that its pres- 
ence produces most profound anaemia. It has been alleged that a 

re form of anaemia may be produce! by the growth of hot 
alus latu* and bacterium termo in the intestines, and that the dis a 
is readily cured by the expulsion of these parasites. When anaemia is 
npanied by a fever, ir s soil -times difficult to distinguish it from 
r rem tit- 1, and from endocarditis an .• but 

the course of the disease generally renders an accurate diagnosis pos- 
sible after a little time. s pro- 



DISEASES OF THE BLOOD. 605 

duce intense anaemia, but these conditions can be easily recognized by 
attention to the general condition of the patient. Primary atrophy of 
the gastric glands also results in a condition that closely resembles pro- 
gressive pernicious anaemia, but this rare disease is sometimes assumed 
to be the cause of pernicious anaemia, so that the relative position of 
the two diseases is not yet fully decided. 

Prognosis. The prognosis is most unfavorable ; although remissions 
and apparent recovery are sometimes observed, it is probable that the 
majority of cases reach a fatal termination. 

Treatment. The patient should be placed under the most favor- 
able hygienic conditions. The most successful remedy is arsenic, which 
may be administered in doses of four or five drops after each meal ; it 
must be administered with great perseverance for a long period of time. 
Iron is not always tolerated, and must be used with caution. The best 
preparations are the sulphate of iron in the form of Blaud's pills, or 
the tincture of the acetate of iron in doses of thirty drops after each 
meal. Phosphorus has been recommended, and in desperate cases the 
transfusion of blood has been performed with temporary benefit. Irri- 
gation of the stomach is said to have accomplished wonderful cures, but 
it is probable that the cases were simple forms of ordinary anaemia. 

Chlorosis. 

Etiology. Chlorosis rarely occurs except among young people of 
the female sex, during the first ten years after the age of puberty. The 
disease is widely diffused, and increases with the spread of civilization 
and its peculiar privileges and disadvantages. It is often associated 
with an imperfect development of the vascular apparatus, which involves 
a condition of general debility and a defective evolution of the sexual 
organs. The disease is frequently observed in families whose members 
exhibit a predisposition to pulmonary consumption, cancer, and nervous 
diseases. 

A predisposition to the disease may be acquired through exposure to 
all forms of mental and physical depression. Sorrow, anxiety, over- 
work, unwholesome food, wasting discharges, and the w T ear and tear of 
female life in an atmosphere of poverty and neglect, favor the acquisi- 
tion of the disease. 

Symptoms. Chlorosis is usually developed in a gradual and insidi- 
ous manner. It sometimes commences at the first menstrual period. 
The patient complains of fatigue, disinclination to exertion, excessive 
desire for sleep, shortness of breath, palpitation of the heart, dyspep- 
sia, and wandering pains in the different parts of the body. The 
menses are frequently irregular, scanty, and accompanied with pain. 
Extreme pallor is one of the earliest symptoms ; the ears appear 
colorless; the lips, the conjunctiva, and the entire surface of the skin are 
pale, though sometimes the color assumes a slightly icteric or greenish 
tint. In certain cases the countenance presents a florid appearance on 
account of the thinness of the skin and the dilatation of its capillaries, 
but an examination of the cavity of the mouth will speedily rectify 



*:■■':■:> DISEASES J THE BLOOD. 

agnostic en irs which have been thus originated. The perspira- 
tion is usually scanty, and the epidermis becomes dry and scurfy. 

Despite the e impoverishment of the blood, the patient 

usually appears plump, and does not lose weight. The subcutai 
fat is often increased, by reason of the imperfect supply of ox . 
to the tissues. Sometimes moderate degree : is isible 

about the face and upon the backs of the hands. 

The spears light colored and watery. The white corpu- 

are not increased in number. The red is d es exhibit great varia- 

tion in size and form (poikd - . and their number is often greatly 

diminished. Tiie haemoglobin exhibits a still greater degree of reduc- 
tion. The amount of iron in the blood is also reduced in quantity. 
The albumino us jonstituents :: the plasma are sometimes diminished, 
but are sometimes increased. 

The temperature of the body is usually unchanged. Occasionally it 
is slightly elevated, but when decided par: - :f fever exist, the 

se is probably one of pernicious anaemia. Tl- subjects :ions 

of cold are greatly increased It is difficult for the patient to keep 
warm. The must is flaccid and weak, so that e 

exertion becomes laborious and fatiguing. The r ; is small, - :r and 
accelerated. The is frequently feeble and hoarse. Catarrhal 

eondi' % :~ :'.-: :e not uncommon. Breath 

ness is a frequent consequence of exertion, and is conditioned by the 
reduced capacity of the blood for oxygen. The h t beats rapidly, 
and feebly : anaemic murmurs are audible over its Yal along the 

urse of the large arteries in veins In many cases it is necessary 
to observe the course of the disc i to perform frequent auseulta- 

: :.. in order to avoid the erroneous _::_ s:s of valvular K - 

Z ' toft) bis not uncommon: when associ- 

ated with a rapid pulse and with prominent eyeballs, the sympton 
exophthalmic goitre are closely counterfeited, if not actually present. 

The apj - is usually diminished, though sometimes it is inordinate 
and capricious. The patient eagerly devours undigestible food or other 
articles of an inedible character, like chalk, slate-pencils, pica). 

An 9J) breath is a common symptom, and various evidences 

re zimonly observed. & is frequently experi- 

_ stric juice is often deficient in hydrochloric acid. Diges- 
tion and absorption are retarded, and the bowels are usually constipated. 

Thr is usually watery, and of a low specific gravity - me- 

times contains traces of albumin, but renal casts are absent. 

■nse* are generally supj i ssed dines, fa they 

occur more or less regularly, but are associated with greal n ; some- 
times there is actual menorrhaj 

Associated with chlorosis may ffuncl 

ffyst rii is not uncommon : convulsions and paralysis are 
sometime- se .id the phenomena of neuralgia, headache, spinal 

irritation, and neurasthenia are frequently observed. 

The existence of chlorosis is sometimes accompanied by a predispo- 
sition to endocarditis, venous thrombosis, bleeding from the nose, con- 
sumption. leucorrho?a. erosion of the uterir. and relaxation of 



DISEASES OF THE BLOOD. 607 

the ligaments of the uterus, permitting displacement and flexion of the 
organ. 

The duration of chlorosis depends largely upon its causes. Some- 
times it is rapidly cured, but too frequently its consequences are greatly 
prolonged, and may become a permanent condition. 

Pathological Anatomy. The rare occurrence of death from 
chlorosis greatly interferes with the progress of knowledge regarding its 
pathological changes. The universal lack of blood is very apparent, 
and all parts of the body are unusually pale. The heart is usually small 
and relaxed; sometimes the right ventricle appears relatively dilated; 
yellowish spots appear in its substance, which upon microscropical 
examination are shown to be the seat of fatty degeneration. The aorta 
is often imperfectly developed in size, so that it resembles one of the 
arteries of the extremities, rather than the principal vascular canal of 
the body. Its walls not infrequently exhibit patches of fatty degenera- 
tion. The sexual apparatus is often imperfectly developed. The breasts 
are flaccid and small, and sometimes contain indurated masses which 
may involve the entire gland. The liver, kidneys, pancreas, and gas- 
tro- intestinal glandular apparatus are frequently in a condition of 
considerable fatty degeneration. 

Diagnosis and Prognosis. Chlorosis can be distinguished from 
secondary anozmia by the history of the case, and by the condition of the 
patient. During the early stages of the disease the possibility of latent 
consumption and cancer should be kept in mind. The favorable results 
of treatment, the absence of fever, and of retinal hemorrhages, distin- 
guish chlorosis from progressive pernicious anamiia. The absence of 
renal casts from the urine differentiates chlorosis from chronic nephritis, 
even though traces of albuminuria and of oedema are present. The 
prospect of recovery is good, though it is true that in many cases there 
exists a predisposition to pulmonary consumption and to endocardial 






Treatment. Nothing positive is known regarding the essential 
nature of chlorosis. It is, however, a matter of experience that the 
disease may be often prevented by attention to diet and hygiene. 
Though fresh air and exercise are of great benefit in cases of chlorosis, 
great caution is necessary in order to avoid fatigue from the excessive 
employment of these therapeutic measures. In like manner, though 
cold sponge baths and plenty of friction with rough towels are exceed- 
ingly beneficial, the indiscriminate use of cold bathing upon the sea- 
coast, and elsewhere, is often attended with unfavorable results. 

Chief among the remedial agents that are useful in chlorosis may be 
placed the preparations of iron ; these should be given in doses such as 
can be tolerated, and their use must be continued for a number of 
months. Among the best of the iron preparations are iron by hydro- 
gen, the lactate of iron, Vallet's mass, the sulphate of iron in the form 
of Blaud's pills, the potassio-tartrate of iron, the tincture of the acetate 
of iron, and the tincture of the perchloride of iron. Constipation of 
the bowels should be relieved by the use of compound rhubarb pills, 
aloes and myrrh, or the granules of aloin, strychnine, and belladonna. 
Much benefit is often derived from the use of mineral waters that con- 



608 DISEASES OF THE BLOOD. 

tain iron. Of these the springs among the mountains of Virginia enjoy a 
well-deserved reputation. Among them may be mentioned the Rawley 
Springs, the Sweet Chalybeate Springs, the Rock Bridge Alum 
Springs, the Pulaski Alum Springs, the Bath Alum Springs, the 
Stribling Springs, the Church Hill Alum Springs, the Bedford 
Alum Springs, the Variety Springs, and the Shenandoah Alum 
Springs. In other parts of the United States, the Bailey Springs in 
Alabama; Fry's Soda Spring, the Geyser Spa, the Napa Soda Springs, 
and the Summit Soda Springs in California ; the Stafford Springs in 
Connecticut ; the Green Castle Springs in Indiana ; the Catosa Springs, 
and the Madison Springs in Georgia ; the Estill Springs in Kentucky ; 
the Schuyler County Springs in Illinois ; the Hopkinton Springs in 
Massachusetts ; the Owosso Springs in Michigan ; Schooler's Mountain 
Springs in New Jersey ; Cooper's Well, and Ocean Springs in Missis- 
sippi ; the Oak Orchard Acid Spring, and the Sharon Springs in New 
York ; the Adams County Springs, and the Green Springs in Ohio ; 
Cresson Springs, Blossburg Springs, and the Fayette Springs in Penn- 
sylvania ; the Mont vale Springs, and the Beersheba Springs in Ten- 
nessee. 

When chlorosis is associated with scrofula, the syrup of the iodide of 
iron should be given three times a day, in half drachm doses ; or pills of 
iodide of iron may be administered together with cod liver oil. When 
gastric disorders exist, iron can scarcely be tolerated. In such cases it 
is advisable to give ten drops of dilute hydrochloric acid in a wineglass 
of warm water, half an hour after each meal. When an inflammatory 
condition of the stomach does not exist, bitters like compound tincture 
of cinchona, and the compound tincture of gentian, are useful. Nux 
vomica and its preparations are also beneficial in such cases. 

The question of marriage during chlorosis is frequently made promi- 
nent. While in many instances a happy marriage is followed by 
speedy recovery, in many other cases it appears to be a complete failure. It 
is probable that in such instances there is an insuperable defect in the 
structure of the vascular apparatus, and in the blood-making organs. 

Melanaemia. 

Etiology. The existence of mdanoemia can only be determined 
by the aid of the miscroscope, which reveals the presence of numerous 
black granules of pigment in the blood. The cause of the disease is con- 
nected with malarial infection. Under the influence of malaria the red 
blood-corpuscles become disintegrated, and their pigment is discharged 
into the blood. The disease is not very common in temperate climates. 
It is usually observed in tropical countries where malaria exists in its 
most deadly forms. The occurrence of melanaemia is therefore de- 
pendent upon the concentration of the poison, and occurs only as aeon- 
sequence of the severer forms of malarial fever. It is supposed that 
the infective parasite, by its action upon the red corpuscles, causes their 
disintegration, and the transformation of their haemoglobin into pig- 
ment. 

Symptoms and Diagnosis. The blood contains numerous pigment 



DISEASES OF THE BLOOD. 609 

granules, which are either carried freely in the plasma, or are included 
in round cells, or spindle-shaped cells which resemble the endothelial 
cells of the splenic veins. Sometimes the granules are included in 
hyaline masses of different shapes. These granules are intimately 
associated with the presence of the malarial Plasmodium, which is 
supposed to constitute the infective agent of malaria. The recently 
formed granules are of a brown or yellow color, which deepens into a 
dark -slate color as their age increases. They do not contain iron. 

In many cases the pigment masses disappear very quickly after the 
subsidence of a febrile paroxysm ; in other cases they continue to cir- 
culate in the blood for a long period of time. 

It sometimes happens that the presence of pigment causes no other 
symptoms, and the disease can only be recognized by a microscopical 
examination of the blood, which reveals the presence of pigment and a 
diminution of the number of red blood-corpuscles. In many instances 
the capillaries in different parts of the body become obstructed with 
pigment, and the symptoms of blood stagnation may be thus locally 
developed. In this way is produced the peculiar yellowish-gray dis- 
coloration of the skin that characterizes malarial cachexia. The 
functions of the brain, kidneys, and digestive organs, are sometimes 
considerably impeded by these minute pigment embolisms, producing 
headache, dizziness, delirium, coma, and occasionally convulsions or 
paralysis. Portal obstruction is followed by diarrhoea, peritonitis, 
or ascites. Renal obstructions occasion suppression of the urine, or 
albuminuria and hematuria. 

Pathological Anatomy. The blood in the portal vein is espe- 
cially rich in pigment. The spleen and the liver contain large 
quantities of the substance, and are frequently enlarged and of a slate 
color, by reason of the presence of coloring matter in the cells and 
vessels of the organs. The same thing is true of the majority of the 
organs and tissues of the body, especially the brain, kidneys, lymph 
glands, marrow, and skin. 

Prognosis and Treatment. Melancemia is attended with con- 
siderable danger in consequence of the intensity of the malarial infec- 
tion by which it is caused. The treatment requires large doses of 
quinine (30 to 60 grains per diem). After the symptoms of fever have 
been subdued, nitric acid or nitro-muriatic acid may be given, in doses 
of five drops of the undiluted acid in a glass of water, three times a 
day. This treatment should be continued for a month or six weeks : 
and if possible a change of air should be secured. 

Purpura — Purpura Simplex. 

Symptoms and Diagnosis. Purpura consists in the occurrence 
of minute hemorrhages into the skin, especially upon the surface of 
the legs and upon the backs of the hands. These spots do not itch, 
and do not disappear on pressure. Their color is at first purple, then 
gradually fading into a brownish, greenish, and yellowish color, as the 
blood pigment becomes transformed at the seat of extravasation. 
Sometimes there is a slight febrile movement, together with symptoms 

39 



610 DISEASES OF THE BLOOD. 

of gastric disorder and universal discomfort, accompanying the devel- 
opment of the eruption. In other cases it produces no constitutional 
disturbance. The duration of the disease is prolonged through one or 
two weeks, and sometimes successive crops of the eruption make their 
appearance. 

Etiology. Very little is known regarding the causes of purpura. It 
is sometimes observed in connection with anaemia and tuberculosis ; 
in other cases it follows one of the infective diseases; or it maybe 
connected with the appearance of the menses. 

Prognosis. Recovery is the rule. Only in rare instances do the 
hemorrhagic spots increase and assume alarming proportions. In such 
cases death sometimes occurs within a few days. 

Treatment. Mild cases require no specific treatment beyond rest 
and good diet. When the disease occurs after other infective diseases, 
or in connection with anaemia, the general treatment of such conditions 
is indicated. 

Rheumatic Purpura — Purpura Rheumatica. 

Symptoms and Diagnosis. In this form of purpura, inflammatory 
swelling of the joints, like that of rheumatism, is associated with the 
cutaneous eruption. In the majority of cases the eruption is preceded 
by a loss of appetite, depression of spirits, and slight symptoms of 
fever. After a few days the joints and the muscles become painful 
and slightly swelled. These symptoms are soon followed by the ap- 
pearance of purpuric patches, of variable size and intensity, upon the 
surface of the skin. The lower extremities are principally involved, 
though the exanthem usually appears also upon the body and upper 
extremities. Sometimes the patches are slightly elevated, and an 
eruption of urticaria may occupy the intervening spaces. In many 
instances a certain amount of oedema is visible about the eyelids and 
upon the lower extremities. Feverish symptoms are sometimes present, 
but are frequently absent. As the eruption appears, the pain and 
swelling of the joints subside. In the course of a week or ten days the 
extravasated blood is gradually absorbed, and the eruption disappears 
after changing color from red to brown, green, and yellow. Sometimes 
the spleen is somewhat enlarged. Occasionally albumin is present in 
the urine. 

The disease continues for one or two tceeks, and relapses are not 
uncommon, so that sometimes its occurrence is prolonged for many 
months. Under such circumstances a high grade of anaemia is usually 
developed. 

Hemorrhage from the mucous membranes seldom occurs, but it has 
been sometimes observed, together with hematuria and gangrene of the 
fauces, followed by a fatal result. These cases manifest an apparent 
relationship with purpura h&morrhagica. 

Etiology. The disease is most frequently observed among males, 
during the first fifteen years of adult life. It is rare among children. 
It is especially frequent among persons of an anaemic and enfeebled 
constitution, especially if they have previously suffered with rheu- 
matism, malarial fever, pulmonary consumption, or cardiac disease. 



DISEASES OF THE BLOOD. 611 

Among females it is sometimes experienced shortly before the occur- 
rence of the menses. 

Pathological Anatomy. Very little is known regarding the patho- 
logical changes that are produced by the disease. The joints contain 
an excessive amount of clear synovial fluid, and the vessels of the 
synovial membranes are injected and ruptured at various points. 
Capillary hemorrhages also exist in the muscles that move the affected 
joints. 

Prognosis and Treatment. The prognosis is almost invariably 
favorable. Salicylic acid and its salts do not seem to exert that influ- 
ence over the symptoms which they produce in cases of ordinary acute 
rheumatism. The special treatment is principally symptomatic, and in 
severe cases is identical with the treatment of purpura hemorrhagica. 

Purpura Hemorrhagica. 

Etiology. The disease occurs more frequently among females than 
among males. It is most common during the first five years after the 
age of puberty, and especially among individuals of a delicate constitu- 
tion. It is a disease of cold weather and harsh climates, where it exists 
more frequently than in milder regions and seasons. It is often 
abruptly originated by exposure to cold and wet, together with insuf- 
ficient and unwholesome food. It is sometimes experienced during the 
period of convalescence from severe infective diseases, like typhoid 
fever, scarlet fever, malarial fever, syphilis, and tuberculosis. It is 
occasionally encountered during the period of pregnancy, or after child- 
birth, and its occurrence is sometimes excited by the medicinal use of 
mercury, phosphorus, and iodide of potassium. 

Symptoms. In the majority of cases the disease is ushered in with 
loss of appetite, general prostration, disturbances of the alimentary 
canal, and a slight fever. These symptoms are soon followed by the 
appearance of hemorrhagic spots upon the lower extremities, and 
extending to the body and upper extremities, but sparing the face. 
The hemorrhagic spots are usually petechial in their character, but 
sometimes they coalesce and form patches of considerable size, present- 
ing the appearance of wheals and stripes (vibices). Like other forms 
of purpura these effusions gradually change color, assuming different 
shades of red, purple, blue, grteen and yellow. Sometimes the epi- 
dermis is raised by the effusion, forming a blood-filled vesicle or bulla 
which may become gangrenous. Hemorrhages also occur sometimes 
from the cavity of the mouth and from all of the mucous membranes of 
the body. Intestinal perforation and peritonitis are sometimes pro- 
duced by gangrenous ulceration, excited by the formation of a hemor- 
rhagic infarct in the wall of the intestine. Hemorrhages into the 
sub-conjunctival tissue, into the retina, and into the brain itself, are 
sometimes observed. 

The blood presents no uniform characteristics. Not unfrequently 
the red blood-corpuscles are diminished in number, and the colorless 
corpuscles are multiplied. The amount of haemoglobin in the corpuscles 
is not diminished. In some cases the coagulability of the blood is de- 
creased. 



612 DISEASES OF THE BLOOD. 

In certain cases the symptoms of constitutional disturbance are very 
slight, but in others there is high fever and great prostration. Hemor- 
rhage into the kidneys sometimes causes inflammation of those organs, 
so that the symptoms of nephritis become prominent as the symptoms of 
purpura subside. Occasionally the disease terminates with delirium and 
coma or convulsions. 

The duration of the disease varies from two to six weeks, though 
death sometimes occurs in the course of a few days ; while in other in- 
stances the case may be prolonged for many months. Relapses are not 
uncommon. 

Pathological Anatomy. The tissues and organs of the body gen- 
erally exhibit considerable ano?mia. Hemorrhages are often visible in 
the internal organs and serous surfaces. The connective tissue of the 
muscles, the fasciae, tendons, and periosteal structures usually escape 
the effects of hemorrhage. A certain amount of fluid, sometimes tinged 
with blood, exists in the serous cavities of the body. The spleen is 
frequently enlarged, and sometimes contains hemorrhagic infarcts. 
Microscopical examination sometimes reveals an amyloid degeneration 
of the capillary walls, and the effort has been made to explain the 
occurrence of hemorrhage by this fact. The lymph glands are some- 
times infiltrated with pigment derived from the degenerated blood 
corpuscles. 

Nothing is known with regard to the actual cause of the disease. 
though many are inclined to regard it as a consequence of some form of 
infection. 

Diagnosis. The disease differs from other forms of purpura through 
the greater intensity of its symptoms. Purpura simplex principally 
involves the external surface of the body. Purpura rheumatica is 
associated with articular changes. Scurvy is characterized by a peculiar 
inflammation and swelling of the gums. Haemophilia differs from pur- 
pura in the fact that it is a congenital and permanent condition, and is 
frequently of hereditary origin. The acute hemorrhagic exanthemata 
are. characterized by high fever, and by the specific symptoms peculiar 
to each disease. 

Prognosis. Purpura hemorrhagica is seldom dangerous, except 
in the cases of pregnant and parturient women, who are exposed to the 
risk of fatal hemorrhage. 

Treatment. Rest in bed is an important factor in the treatment of 
purpura, since hemorrhage of a dangerous character is sometimes pro- 
voked by premature return to active habits. The diet must be light 
and cooling, and the bowels should be opened daily. In ordinary cases 
aromatic sulphuric acid, in doses of ten drops every four hours, will 
prove a sufficient remedy. If signs of debility make their appearance, 
the compound tincture of cinchona may be given, in drachm doses every 
four or five hours ; or tonic doses of quinine and sulphuric acid : 

R. — Quin. Biilph. ....... gr. xxxij. 

Strych. sulph gr. j. 

Acid, sulph. arom. . . . . . • o.i- 

Syr. zingiber ^ij. 

A.q. destill ^xxix. — M. 

S. — Give one teaspoonful in a wineglass of water every four hoars. 



DISEASES OF THE BLOOD. 613 

Other remedies, e.g., ergot, acetate of lead, oil of turpentine, and the 
astringent preparations of iron, have been employed without any par- 
ticularly good effect. 

Scurvy — Scorbutus. 

Etiology. Scurvy is a disease that is caused by defective nutrition. 
Sometimes this is a consequence of an insufficient supply of food. In 
other cases it is dependent upon the use of tainted articles of diet ; 
hence the frequency with which the disease occurs during famine or 
among the inhabitants of beleaguered cities in time of war. An im- 
perfect and vitiated water-supply is supposed to contribute toward the 
occurrence of the disease. In many cases, however, scurvy occurs in 
consequence of an improperly selected diet, even though the quantity 
and the quality of the food be all that can be desired. This has been the 
frequent experience of seafaring people who are for a long period of 
time deprived of fresh vegetables, though abundantly supplied with 
salted meats and bread. In many cases a deficiency of fat food has 
been assigned as a cause of scurvy. 

The effects of insufficient or improper food are greatly aggravated by 
exposure to fatigue and cold and wet. For this reason the hardships 
of a sailor's life are particularly favorable to the occurrence of scurvy. 
It is in cold, northern climates that the disease is most commonly en- 
countered, though the experiences of the British navy in past ages have 
shown that scorbutic epidemics may rage with the utmost severity with- 
in the tropics. 

The more frequent occurrence of scurvy in the male sex, during 
the active years of middle life, is simply a consequence of the fact that 
exposure to its causes is most commonly experienced by men during 
the most enterprising period of their existence. The disease is less 
frequent among robust and vigorous individuals of the upper classes 
than among the poorer members of society. The intemperate, and those 
who have been debilitated by malaria, syphilis, and other exhausting 
diseases, are particularly liable to an attack of scurvy. 

The disease is not limited to the ranks of soldiers and sailors. It 
may occur upon land as well as upon sea, wherever poverty and misery 
are prevalent. 

Symptoms. The outbreak of scurvy is usually preceded by the 
development of anosmia and debility, which gradually increases until 
the characteristic symptoms of the disease make their appearance. 
Among the earliest symptoms is an inflammatory swelling of the gums, 
which become soft, spongy, and swelled around the teeth. This symptom 
does not make its appearance in young children and toothless old peo- 
ple. The swollen gums exhibit a bluish color, and bleed very easily. 
The teeth become loosened in their sockets, and frequently fall out. In 
many instances ulceration and necrosis of the inflamed tissues take 
place, so that the mouth becomes filled with putrefactive microorgan- 
isms, and the breath exhales a frightful fetor. This process rarely 
extends to the lips and cheeks, since they are not exposed to the injuries 
to which the swelled and bleeding gums are exposed during the act of 
mastication. 



614 diseases :i rHi blood 

While the inflammatory processes are progressing n the mouth. 
i make their appearance in the si 
areolar tissue. The hemorrhagic spots are most numerous upon the 
lower extremities, but they also appear upon the body and upper 
extremities scarcely ever invading the face. Any unusual pressure 
upon the surface of the skin, or compression of the flesh, is liable to 
be followed by interstitial hemorrhage. Sometimes vesicles and bullae 
that are filled with blood make their appearance. Their rupture is 
followed by ulceration, and sometimes by gangrene. Subcutaneous 
hemorrhages are frequently very exten- eeially when provoked 

by any violent exercise or traumatism. Sometimes they are fol. 
by thickening of the connective tissue, and by the formation of perma- 
nent indurations and adhesions between the skin and the underlvins 

. _ 

structures; so that the patient may be more or less crippled by con- 
tractures and deformities involving the extremities. Clu 7 -~ t is some- 
times thus produced. In other cases the joints become ankylosed. and 
the muscles undergo atrophy. When the skin gives way over one of 
these hemorrhagic effusions rive ulceration may exist for a long 

period of time. These ibrmidable lesions are most common in the 
lower extremities. Sometimes the roots of the nails become ulcerated, 
and the nails themselves are thrown off. 

Copious hemorrhage from any portion of the : the 

bodv is a not uncommon event. Sometimes the joints become swelled 
and painful, and their inflammation may be followed by destruction of 
the articular surfaces and by ankyl : a :■ a si on ally hemorrhage 

takes place under the periosteum and into the ep *es of i 
The I 88 of the body may also be invaded by hemorrhagic 

effusion and inflammation. The chambers of the eye and the 

vnctfaal ' - metimes exhibit the same hemorrhagic condition, 

and in certain cases the eyesight is permanently lost through disorgani- 
zation of the eyeball. The phenomenon of her. is not uncom- 
mon, but its cause has not been explained. 

The evolution of thr lisease is :^panied by increas _ 

and caehezi i. Fever does not often occur, unless . by the occur- 

rence of inflammation and the formation of absc e ss es . The usual 
[uences of a are exhibited by the heart. The spleen is 

sometimes enlarged, and diarrhoea or dysentery frequent. its The 

is generally reduced in quantity and contains albumin . 
specific gravity is frequently low. and its chemical composition is quite 
variable. The blood frequently contains very little fibrin. The color- 
acles are usually increased, while the red corpuscles are 
considerably diminished in number. 

The leasee nerally manifests a subacute and chronic 

form. It may last for many weeks. th<-:_ sometimes a 
tion is quickly reached. This may result from exhaustion, or from f 
sive effusion into the pleural or pericardial cavities. It may result 
from pneumonia, or from uncontrollable hemorrhage, or from the occur- 
rence of septicaemia. The progress of is usually very tedious 
and frequently interrupted Uy relapses, unless the most favorable 
ditions are present. Pneu is probably the most common compli- 



DISEASES OF THE BLOOD. 615 

cation of scurvy. It frequently originates in hemorrhagic infarcts 
within the lungs, and it tends to assume a low form that sometimes 
terminates in gangrene. Dysentery and other infective diseases are 
often associated with scurvy. 

Pathological Anatomy. Rigor- mortis is but slightly developed 
after death, and decomposition advances rapidly. The hemorrhagic 
effusions that take place under the skin, and elsewhere, remain dis- 
tinctly visible, and sometimes the process of transformation of the exu- 
date into connective tissue appears considerable advanced. Fractures 
are often found disunited through absorption of the newly formed bone, 
and the callus disappears if the fracture be recent. Lymphoid cells 
are predominant in the marrow of the bones. The articular cavities 
contain serous or sanguinolent liquid ; hemorrhage and softening are 
visible in the articular cartilages and synovial membranes, and occasion- 
ally a purulent exudation is discovered. A similar condition is pre- 
sented by the other serous cavities of the body. The blood is thin, and 
does not readily coagulate ; its quantity is often greatly reduced, and 
fatty degeneration is frequently observed in different organs as a con- 
sequence of the impoverished condition of their nutrient fluid. The 
heart is soft and pale, and often exhibits circumscribed regions of fatty 
degeneration. Sometimes inflammatory changes involve the cavities 
and valves of the organ, and hemorrhages are common beueath its epi- 
cardial investment. Similar hemorrhages are often visible under the 
mucous surfaces of the air-passages. The lungs are sometimes oedema- 
tous, or inflamed as a consequence of pneumonia or hemorrhagic infarc- 
tion which occasionally leads to pulmonary gangrene. The spleen is 
usually enlarged, and frequently contains hemorrhagic infarcts. A 
similar tendency to hemorrhage is apparent in the mucous membrane 
of the stomach and intestines. Follicular ulceration and necrosis are 
also a common incident. The liver is fatty, and frequently invaded by 
scattered points of hemorrhage. The kidneys usually escape serious 
injury, but the universal tendency to hemorrhage is apparent in the 
course of the urinary passages. 

The real nature of scurvy is unknown. The opinion has been ex- 
pressed that it is an infective disease, but no satisfactory evidence of 
this has yet been forthcoming. Among the most plausible explana- 
tions is that which ascribes the disease to a deficiency of the organic 
salts of potassium in the diet. But while the fact of their reduction is 
true, the connection of this fact with the phenomena of the disease has 
not yet been clearly established. 

Diagnosis and Prognosis. Scurvy is a disease that can be 
scarcely mistaken for anything else. The condition of the gums is 
highly characteristic, and resembles nothing else. The prognosis is 
favorable when proper food can be secured, but in advanced cases, 
especially if complicated by other diseases, a fatal result is not un- 
common. 

Treatment. The most favorable results in the management of 
scurvy are obtained through the adoption of prophylactic measures. If 
wholesome water, fresh meat, and an abundant supply of vegetables, 
especially potatoes, are furnished, the existence of scurvy is rendered 



616 DISEASES OF THE BLOOD. 

impossible, even during long voyages. Apples, oranges, cabbage, 
onions, and all kinds of fresh fruits and vegetables, are particularly 
useful. A daily ration of lime-juice is an efficient preventive of the 
disease. It is frequently served out to seafaring men, together with a 
small quantity of spirits, to make it more palatable. It is also a matter 
of great importance to avoid exposure to wet and cold, and to procure 
sleep in dry and well-ventilated apartments. When the disease has 
been already developed, it is sufficient to supply the necessary articles 
of food, in order to witness rapid recovery without other remedies. The 
various plants of the cruciferous order are all useful, and the narratives 
of ancient mariners abound in references to the good effects of scurvy- 
grass, pepper-grass, mustard, water-cress, cabbage, cauliflower, and 
even green grass itself. The different organic salts of potassium have 
also been employed, though with rather indifferent success. During 
convalescence various preparations of iron, quinine, strychnine, and 
other bitters, are useful. Ulcers upon the external surface require 
ordinary surgical treatment. The mouth should be frequently cleansed 
with a solution of chlorate of potassium or of permanganate of potas- 
sium. Painful ulceration of the gums is sometimes benefited by the 
local application of nitrate of silver. 

Paroxysmal Hemoglobinuria — Hemoglobinuria Paroxysmalis. 

Etiology. Paroxysmal hemoglobinuria is usually observed in the 
male sex alone. Its causes are not well understood. It sometimes 
follows rheumatism, intermittent fever, syphilis, Bright's disease, 
debauchery, disturbances of menstruation, mental agitation, and other 
causes of depression. The disease is usually experienced during the 
cold months of the year, and its paroxysms are frequently excited by 
exposure to cold, or by immersing the hands or feet in cold water. 

Symptoms and Diagnosis. Paroxysmal hemoglobinuria is char- 
acterized by the appearance of haemoglobin in the urine. This occurs 
intermittently, and usually follows exposure to cold. During the in- 
tervals between the paroxysms, the urine exhibits no unusual departure 
from the normal standard, though sometimes a transient albuminuria 
has been noted. The invasion of the paroxysm is accompanied by 
sensations of cutaneous irritation, with pain in the joints, sensitiveness 
to pressure over the liver and kidneys, and a feeling of general discom- 
fort which culminates usually in a chill, followed by fever and perspira- 
tion that continues for a few hours, and then gradually subsides. The 
duration of the paroxysm may vary from two or three hours to a 
week. It is not unusual to see an eruption of urticaria upon the skin 
during the attack. Occasionally the temperature is reduced below the 
normal standard, and sometimes an icteric tinge appears upon the skin 
and conjunctiva. If blood be drawn and permitted to coagulate, the 
serum is stained with haemoglobin, showing that many of the red blood- 
corpuscles have undergone dissolution, and have discharged their color- 
ing matter into the plasma. The red corpuscles also exhibit great 
variation in size and form. It appears that the blood-making organs 
furnish corpuscular elements which too easily break down and give up 



DISEASES OF THE BLOOD. 617 

their haemoglobin. Very considerable anaemia is thus sometimes 
produced. 

Pathological Anatomy. With the exception ot the changes 
already described in the blood, very little can be learned from post- 
mortem examination. The kidneys usually appear enlarged and 
hyperaemic, but otherwise exhibit nothing unusual save an occa- 
sional deposit of pigment in the renal epithelium. 

Prognosis. The disease usually recovers under treatment ; still, 
relapses are often experienced, rendering the prognosis somewhat 
uncertain. 

Treatment. The avoidance of exposure to cold and fatigue consti- 
tutes the most important prophylactic measure. If the disease appears 
to be dependent upon the preexistence of syphilis, favorable results are 
often obtained from anti-syphilitic treatment. Anaemia should be 
treated with iron, etc., as indicated by the symptoms. 

Haemophilia. 

Etiology. Haemophilia is a condition characterized by a congeni- 
tal or hereditary predisposition to uncontrollable, and, frequently, fatal 
hemorrhage. The predisposition is usually hereditary, so that certain 
families are by the public recognized and nicknamed as bleeders, by 
reason of this peculiarity which is transmitted from generation to 
generation. The predisposition is usually manifested by the male 
members of such families, though it is transmitted chiefly through the 
female sex. Sometimes the predisposition is transmitted indirectly 
from the grandparents to the grandchildren, while the intermediate 
generation manifests no symptom of the tendency. It has also been 
noted that when a male bleeder marries a healthy wife, his descendants 
usually escape the incidence of haemophilia, while if a healthy man is 
united with a woman from an haeinophilic family, though she may 
never experience the disease, her descendants manifest the predis- 
position. 

Though the disease is usually hereditary, it sometimes originates as 
a congenital affection. The cause of such congenital predisposition is 
not understood, though it has been ascribed to various unfavorable con- 
ditions of health on the part of the parents. Occasionally haemophilia 
seems to originate spontaneously at a somewhat advanced period of 
life, but it is probable that in such cases a predisposition, either heredi- 
tary or congenital, had been overlooked by reason of the absence of 
exciting causes for its manifestation. 

Symptoms and Diagnosis. The existence of hcemophilia is usually 
discovered through the occurrence of obstinate and profuse capillary 
hemorrhage after some slight injury or surgical operation. Among 
females it is sometimes the cause of excessive menstruation, and it may 
determine fatal hemorrhage at the time of childbirth. Individuals 
who manifest the haemophilic predisposition are usually of a delicate 
organization, slender frame, blond complexion, blue eyes, white teeth, 
thin skin through which the bloodvessels are distinctly visible, and they 
manifest a remarkable tendency to blushing upon the slightest provoca- 



618 DisiASzs :.• :hz :::::, 

The disc se is frequently ass::, ted with in in the muscles, 
and neuralgic - - >ns in the teeth and in the joints Excel 

tot an uncommon event. The disc 
tsdf : the time : birth in the fonn of persistent hemor- 
rhage from tl thoogh this may also result from a 
peculiar form of bacterial infection. The occurrence of | 
hemorrhage is accompanied by the usual symptom- :: :;:eniia and 

. t I is most freq uently disci] ged from the n : a 

from the skin. Hemorrhage from the internal n membra:. 

Less fine served Sometimes bl nod accumulates in the cavities 

of the nts, n m j beet me the : use if their disorg ligation. When 
hemorrha^T : kes place beneath the skin the effusion may become puru- 
md the affected tissues may intc . .. ' - :: gan- 

grene. 

Slight injuries are frequently followed by persistenl ratal 

hemorrhage. In this way the exti I : :h may be followed by 

death. Among tir Jews circumcision has in like manner led to a 
fatal result The application of leeches or cups, and all incis is :fthe 
skin, are liable : : be followc ogerc as flow : : bloc . :iich oozes 

from the capillaries, without the implication ■:: ay : msiderable a 
vessel. It has been ibserved : I slight wounds are more dangerous 
than those : greater, extent, and hemorrhage has sometimes been 
■nested by the simple pro: ;; :: enlarging the >riginal wound. The 
operation F vaccinatum, fortunately, loes not seem 1 with 

any danger. The blood thai is effused r. first resents norma] 
tenstics, if with the rogress : hemorrhage it becomes :hin and 

very little leparture from the normal st 
ard. The : ::i^ulabilitv of the blood is somewhat reduced, and there is 
some variation in the constituents of the plasma, but this follows no 
rm rule. 
Pathological Anatomy. The tt-martem ~ after 

death : . haemophilia - ssents little th tis .haracteristic or instructive. 

: He r is . id sometimes I 

- ration. The heart is usually small, and the ar* 
are less than usual size. Their walls Is thinner than normal. 

Sometimes the walls of - srable prolifei 

of their cellular e. Is, seas also, 

- g red. It seems probable 1 tl .-■;--. 

g if reduction of the num v lorless bl 

g a diminution of the _ f the 

blood. _ ndition of the vascular walls that : 

transudation of the blood itself. But tfa s stal nent of facts fun 
no explanation of the primary reduction of the number of the col 
- 
Pl 5H The prognosis - ways rery _ 

Many of the children in such families die before the tent nd it 

- - lorn the case that advance ge is L Some! - -ver, 

the pred> seems to d< - _ - of tin: - 

that after full growth and adult life have been reached, it may com- 
pletely disappear. 



DISEASES OF THE BLOOD. 619 

Treatment. Prophylatic treatment consists in the attempt to regu- 
late the marriage of persons, especially women, who manifest the pre- 
disposition to haemophilia. It is also desirable to avoid all exposure to 
wounds and other causes of hemorrhage. The diet of such patients 
must not include articles of an exciting nature, like alcohol, tea, and 
coffee. When hemorrhage actually takes place, it becomes necessary to 
resort to all the surgical measures that are prescribed for stanching the 
flow of blood. Astringents, such as the persulphate of iron, gallic acid, 
ergot, acetate of lead, etc., have been prescribed, but without much 
apparent success. Saline cathartics are useful, if the bowels are con- 
stipated, or if evidence of local congestion be manifested. The attempt 
has been made to counteract the consequences of excessive hemorrhage 
by transfusion of blood or saline solutions, but this method of treat- 
ment is liable to failure, since it involves the infliction of a second 
wound. The anaemia that is produced by bleeding soon disappears 
after the cessation of hemorrhage. 



PART VIII. 

DISEASES OF NUTRITION. 



CHAPTEE I. 

RICKETS— RACHITIS. 

Rickets is a disease usually observed among children during the 
period of first dentition. It is characterized by certain deformities of 
the bones that result from imperfect ossification. 

Symptoms. Rickets occasionally develops before birth. Sometimes 
the tendency is apparent at the time of birth, especially among children 
who are prematurely born, or who are the offspring of juvenile and 
feeble mothers. In rare cases the manifestations of the disease are 
delayed until the period of second dentition, but in the majority of 
cases it is during the period between the sixth and thirty-sixth months 
that the morbid process is most conspicuous. The earliest symptoms 
are connected with disorders of the alimentary canal. There is diar- 
rhoea, abdominal distention, nocturnal perspiration, paroxysmal fever, 
tenderness of the bones, disinclination to assume the erect position, and 
great debility. (Fig. 124.) The child appears fretful, restless, and 
suffering. In many cases the gastro-intestinal disorders are exceed- 
ingly obstinate. Diarrhoea alternates with constipation ; the perspiration 
and the stools are unusually acid. Sometimes, however, osseous de- 
formities appear without any preceding dyspeptic symptoms. 

Deformity of the skeleton usually commences with swelling of the 
bones of the ankles and wrists. The condyles of the femur are 
then invaded, and presently the anterior extremities of the ribs be- 
come enlarged. The long bones of the leg and of the thigh (Fig. 
125) are frequently curved outward; the spinal column becomes bent 
and twisted ; the sternum protrudes ; the thoracic wall is laterally 
flattened, while its lower portion bulges over the abdomen ; the clavicles 
and the scapuhe also exhibit deformity; the pelvis is flattened and con- 
stricted; the cranial bones are flattened posteriorly; the frontal promi- 
nences become more conspicuous ; the biparietal diameter of the cranium 
is increased ; the face appears small by contrast with the bulging 
cranium, and the jaws are prominent and misshapen. These deformities, 
it is true, may not be present in every subject. Certain portions of 
the skeleton often escape change, but all parts are liable to suffer from 
the disease. 



622 



DISEASES OF NUTRITION 



The characteristic deformity of the skull is caused by the tardy 
closure of the fontanelle; it sometimes remains open until the third or 
fourth year of life. The different sutures are slowly completed, and 
the cranial bones become thickened along their margins. This tardy 
ossification permits the brain to enlarge in every direction, and the 
skull consequently assumes somewhat of the form that characterizes 
hydrocephalus. There is, however, a marked difference between the 
mental condition of the dull and undeveloped hydrocephalic infant and 
the lively intelligence that frequently characterizes the rachitic child. 
The effects of pressure upon the posterior part of the skull are sufficient 
to explain the flattening and deformity that is observed when rachitic 
infants are permitted to lie for a long time with the back of the head 
pressing upon a hard pillow. 



Fig. 124. 



Fig. 125 





Rachitic genu valgum. Child four 
years old. (Schreiber.) 



Rachitic incurvation of the bones. 
(Schreiber.) 



Very characteristic are the deformities that are manifested by the 
bones of the face. The curve of the lower jaw approaches a right 
angle, and its alveolar border inclines inward in consequence of the 
yielding of the bone to the traction of the masseter and genio-glossus 
muscles. The anterior portion of the upper jaw is rendered prominent 
by the pressure of the tongue during the action of suction. The 
superior maxillary bones are compressed so that the arch of the hard 
palate is narrowed and elevated. These facial deformities, of course, 
may be entirely absent in many cases, or present in a minor degree 
only. 

The process of dentition is greatly retarded. When the incisors 
appear later than the ninth month the existence of rickets may be 
suspected. The teeth are frequently thick and square; the enamel 
is not evenly distributed, and appears as if eroded at different points 



RICKETS — RACHITIS. 623 

upon the surface; these erosions assume various forms. When the 
second set of teeth appear, their incisive margins are frequently 
crenated, and they rapidly decay and crumble away. 

When the spinal column is invaded by the disease there is an 
increased convexity of the dorsal curve in the thoracic region (kypho- 
sis), and there is lateral curvature with the convexity towards the right 
(scoliosis). The compensatory curvature in the opposite direction is 
developed in the cervical and lumbar portions of the spine. At the 
same time the vertebral column is twisted around its axis in such a 
way that the bodies of the vertebrae are directed toward the lateral 
convexity. The angles of the ribs upon the side of the convexity 
become therefore more prominent posteriorly, while upon the opposite 
side of the thorax the ribs are flattened. The most prominent portion 
of the back is consequently beneath and below the right shoulder-blade. 
Upon the anterior portion of the thorax there is a compensatory prom- 
inence of the ribs upon the left side, while they are depressed upon the 
right side of the sternum. In many cases these deformities do not 
appear, and the principal evidence of disease involving the thoracic 
structures is furnished by an enlargement of the anterior extremities of 
the ribs. In many cases, however, the lateral walls of the thorax are 
compressed, and the sternum, arching strongly forward at its middle 
portion, is shortened and flattened like the breastbone of a bird; hence 
the term pigeon-breasted that is applied to such children. At the 
same time the base of the thorax is frequently expanded, through the 
enlargement of the liver and the distention of the stomach and intestines. 

The scapulas and the clavicles are frequently thickened and deformed 
in a manner that corresponds with the deviations of the thoracic wall. 
The pelvis undergoes various modifications, by reason of the weight of 
the superincumbent trunk and the upward thrust of the femoral bones 
upon which it is supported in the standing position. The antero-pos- 
terior diameter of the superior strait is shortened ; the oblique diameters 
are usually diminished ; the transverse diameter undergoes less altera- 
tion, and the inferior strait usually escapes deformity. The anterior 
superior spinous processes of the iliac bones are pressed outward ; the 
concavity of the sacrum is diminished or completely obliterated, and 
the angle of the pubic arch is considerably increased. In many cases 
the pelvis is symmetrically deformed by the crowding inward of the 
sacrum and the cotyloid cavities toward the central point of the supe- 
rior strait. In other cases the pelvis is laterally flattened, and its ver- 
tical axis deviates correspondingly from the perpendicular, as if the 
plastic bones had yielded to a weight that bore chiefly upon one side of 
the framework. This constitutes the scoliotic form and variety of 
pelvic deformity. 

Rachitic deformity of the cranium produces less injury of the cere- 
bral functions than might have been anticipated. In many instances 
the degree of intelligence is fully equal to that of other children. The 
deformities of the thorax, however, exercise an unfavorable influence 
upon the functions of the heart and lungs. The heart may be dis- 
placed, and its movements are often rendered unusually conspicuous 
by its close application to the thoracic wall. Sometimes the organ 



624 5EASES . y WUTRITIOX. 

hied by of the hindrance to its movements 

sioned by the deformity and aent of the adjacent ribs. 

The lungs are similarly confine :n their movement m 

that they cam. H in to their normal size. Emphysema 
quentry often and all broncho-pulmonary ac see are 

attended with Unary danger : the difficulty with which blood 

finds its way through the | sels reads upon the righ: 

of the heart and prodacee its iilatation. The vesicular murmur is 
diminished in those portions : the lungs that are compressed in the 
neighborhood of the spinal column, while the opposite portion of the 
thorax is very resonant, and the res ratory sounds assume a puerile 
character. 

Pel \ej • aire gre ■■: importance through the >be< 

which they present : the act of partoriti d 

In cases that are characterized by excessive left - . of the I 
locomotion may be seriously hindered. The knees sometimes interfere 
by reason of the extreme incurvation of the long ' >nee :: :he lower 
extremities genu valgum ; but moderate curvature of the long bones 
snot seriously interfere with the movements of the patient. 

The :: the bones that is rickets leads to the 

frequent occurrence if i . This is often partial, involving only 

:_r sub-periostea] r wrtions >i the : me These fractures maybe produced 
y sample muscular contractions, or by other trifling causes. Reunion 
is sometimes imperfectly accomplished, and a false joint may result at 
the point of injury. 

A tendency to Jo. is sometimes / parent in the 

of rickets, but it is not p< mliar to the disc 

Pathological Axatomy. The lei \ f -"-.:.* are principally 
manifested in the bony skeleton, and are dependent upon an insufficient 
supply and inferior quality of the elements that are needed for the 
r development of the bones. I g the I of healthy devel- 

opment an I _. >wth, the hyaline cartilage of the epiphysis is sep:-.: 
from the full;: by a thin layer of tissue composed of 

cartilage cells which by their multiplication form the framework for the 
: stc sts, that are finally transformed inl 
lis infiltrated with calcareous salts. 

In a - ice that intervenes between the epiphysis 

and the medullary cavity consists lis scupied by. four distinct 

layer- of - Of these, the first - layer of hyaline cartilage : next 

to this lies a thick stratum of ca: _ state of active :ion : 

the surface of this layer that lies nearest to the bone is rendered very 
irregular by the protrusion of numerous pi as - in the direction of 
the ossified tissue : these processes lie in a third layer of si 
substance which is red - s if the shaft of the bone 

had I i s liked in an acid fluid: this - caused 

f the nutritive pi sses unected with ossification. 

Sometimes this gy layer occupies nearly all the space between the 

epiphysis and the diap 3 a the bone: it closely resembles in ay 

ance the skeleton of a delicate sponge : its alveolar spaces contain a thin 

diary substance of a red c : lining numerous blood corpus- 



RICKETS — RACHITIS. 625 

cles and round cells that are sometimes loaded with pigment ; the par- 
titions between these cavities resemble imperfectly formed osseous sub- 
stance, and are usually described as consisting of morbid cartilaginous 
structures, more or less infiltrated with calcareous matter. 

The portion nearest to the diaphysis consists of ossified tissues that 
have undergone more or less alteration, of which the extent and 
severity is dependent upon the degree of development which had been 
reached by the ossifying tissues in the neighborhood of the diaphysis, 
before their invasion by the rickety process. 

The sub-periosteal tissue along the shaft of the bone manifests similar 
disturbances of the process of ossification. These tissues are soft, 
thickened, and more vascular than in the normal condition. The 
maximum of swelling is reached about the middle of the shaft of the 
bone. The periosteum appears loosened, and so copious is the morbid 
supply of blood that the sub-periosteal substance might be easily mis- 
taken for an inflammatory exudation. The swelling and thickening of 
the morbid structures is so great that the medullary canal of the bone 
itself may be constricted by the encroachment upon its cavity that is 
thus effected. As the disease progresses this morbid tissue becomes 
condensed and serves as a bond of union between the periosteum and 
the subjacent bone. It also forms the substance of the callus that con- 
nects the fragments of rickety bones that have undergone fracture. 

Within the medullary canal of the shaft of the bone the process of 
ossification is perverted, as it is elsewhere. The diseased bone becomes 
excessively vascular ; the calcareous salts are dissolved and removed, so 
that in well-marked cases less than one-third of the normal quantity 
remains in the tissues ; and the osseous structure becomes transformed 
into a spongy mass in which may be distinguished the remnants of 
ossified matter which give only an imperfect degree of solidity to the 
morbid tissue. As a consequence, the bone is incapable of supporting 
the weight of the body, and is either fractured by the sudden applica- 
tion of moderate force, or is gradually bent and twisted by the pro- 
longed action of unequally antagonistic groups of muscles. Similar 
morbid processes effect the changes that are observed in the flat bones 
of the body. 

The arrest of the morbid process in a rickety bone may be followed 
by the deposit of solid matter in the diseased tissue. An ivory-like 
hardness is produced by this infiltration ; the bone becomes solidified 
and condensed to a degree that interferes with its nutrition and further 
growth. In this way premature ossification of the cranial sutures may 
occur, permanently limiting the capacity of the cranium. Long bones 
may be in like manner prevented from reaching their full growth. 

Fortunately, however, in the majority of cases, the process of recov- 
ery is usually effected by gradual absorption of the spongy substance 
that has been the seat of disease. The normal course of ossifica- 
tion is resumed, and recovery may be thus completely effected, though, 
in many instances, an irregular outline and uneven surface remain as 
permanent indications of former disease. 

When a rickety bone is fractured, displacement of the fragments is 
usually prevented by the thickened periosteum ; such fractures are fre- 

40 



626 DISEASES OF NUTRITION. 

quently partial in their character, like those which may be produced 
within the bark of a green stick, that is bent at an acute angle, without 
actual rupture of its fibres. 

Etiology. The actual nature of the causes that determine the 
errors of nutrition by which the phenomena of rickets are produced 
remains hidden in the arcana of molecular chemistry. It is possible at 
present to indicate only the predisposing causes of the disease. 

The fact that rickety processes are usually manifested during the 
first three years of life is dependent not so much upon the particular 
influence of age as upon the character of the diet that is supplied to 
the patient during that period. Children who are properly nourished 
do not manifest the disease. 

Hereditary influences appear to operate in a similarly indirect man- 
ner. Rickety patients beget rickety offspring, not because the disease 
is transmissible, but because the children of enfeebled parents are 
peculiarly liable to errors of nutrition and to faulty alimentation 
before and after birth. In like manner scrofulous, tubercular, and 
syphilitic parents may have rickety children, not because rickets is an 
hereditary legacy from those diseases, but by reason of the unfavorable 
conditions of nutrition which attend the ante-natal development and 
subsequent growth of such offspring. 

The influence of climate upon the manifestation of rickets is well 
marked. The disease exists in cold northern countries, and is rarely 
observed in tropical climates; it seldom occurs at any considerable 
elevation above the level of the ocean, but it is commonly witnessed 
among the inhabitants of cold, damp, and low-lying territories. It is 
among the impoverished inhabitants of such unwholesome regions that 
the disease is most frequently experienced. 

A fruitful source of the defective nutrition that fosters the develop- 
ment of rickets exists in the inability of mothers to nurse their chil- 
dren. This defect, though natural enough among the impoverished 
victims of hereditary disease and hygienic neglect, is not unfrequent 
among the members of the upper classes in society. The mode of 
education and the social customs that prevail in modern civilization are 
extremely prejudicial to the function of lactation. Comparatively few 
of the women who have been born and brought up in the whirlpool of 
city life are capable of nursing their children ; if they succeed with 
the first, a perceptible reduction of capacity is observed with each 
successive child, and frequently it is impossible for the later-born 
children to obtain anything like adequate nourishment from the mater- 
nal breast. Under such circumstances, since in the majority of families 
a healthy wet-nurse cannot be procured, artificial substitutes for the 
mother's milk are employed, too often without adequate knowledge of 
the precautions that are necessary to prevent the immediate effects of 
unhealthy food. The artificial substitutes for mother's milk with which 
the market abounds contain starchy elements that are unfitted for the 
proper nutrition of the nursling child. Gastro-intestinal catarrh soon 
appears, and if life be not quickly terminated by inflammation of the 
alimentary canal, the train of morbid processes that terminates in 
rickets is speedily established. Very few are the bottle-fed children 



RICKETS — RACHITIS. 627 

who do not sooner or later manifest some of the symptoms that indi- 
cate disturbances of the process of ossification in some portion of the 
bony skeleton. 

The dyspeptic disturbances above noted tend to disturb the normal 
reactions of the digestive fluids within the alimentary canal. The gas- 
tric juice becomes impoverished, and the normal alkalinity of the in- 
testinal contents is reduced. Lactic acid and other organic acids appear 
in excessive amount. It has been shown that these acids interfere 
with the assimilation of the phosphate of calcium. When lactic acid is 
present in excess the earthy phosphates disappear from the tissues and 
are augmented in the urine. It is a fact of daily observation that the 
perspiration, feces, and other excrements of rickety patients manifest 
an inordinate degree of acidity ; this acid dyscrasia is most intimately 
associated with the failure of calcification in rickety bones. It is pos- 
sible, moreover, that the luxuriant proliferation that is manifested by 
the cartilaginous and spongy tissues which are the seat of disease is due 
to the removal of that calcareous framework by which, under normal 
conditions, the inordinate cellular growth would have been moderated. 

Diagnosis. Well-pronounced forms of rickets can be easily recog- 
nized ; only the incipient and moderate forms present any difficulty. 
Irregular and tardy appearance of the teeth, copious perspiration from 
the scalp, chronic diarrhoea, and nervous irritability are indications of 
a rickety tendency. Chronic hydrocephalus produces a deformity of 
the skull that resembles the rickety form, but it is usually accompanied 
by convulsions and idiocy. Osteomalacia is rarely observed among 
children. Congenital syphilis sometimes causes deformity of the 
epiphyses at the very commencement of life, but it is associated with 
characteristic eruptions upon the skin and mucous membranes. 

Prognosis. The prognosis in rickets is not very unfavorable if 
other complications be not associated with the disease, and if whole- 
some food can be procured for the patient. Osseous deformity some- 
times undergoes spontaneous improvement, but usually the consequences 
of severe rickets remain permanently impressed upon the skeleton. In 
later life pelvic deformities may occasion great difficulty and danger in 
the act of parturition. When the spinal column and the thoracic wall 
are considerably misshapen a predisposition to intra-thoracic diseases is 
thus established. 

Treatment. The prophylactic treatment of rickets requires atten- 
tion to the health of the pregnant mother. Juvenile marriages should 
also be discouraged. The infant after birth should be nursed for at 
least eight months ; and if the mother's milk is insufficient or unwhole- 
some, a healthy wet-nurse should be secured, if possible. All digestive 
disorders should be noted and treated at the earliest possible period. 
The period of lactation must not be too greatly prolonged, since the 
mother's milk, under such circumstances, becomes impoverished in 
quality, and does not supply a sufficient amount of calcareous salts for 
the proper nutriment of the bones. 

Rickety children usually exhibit inordinate distention of the abdo- 
men ; this is caused by dilatation of the stomach, and by excessive 
flatulence in the intestines, consequent upon indigestion. If the diet 



628 DISEASES OF NUTRITION. 

contain too much sugar and starch, these substances are decomposed, 
and lactic acid is liberated in excess. The acid contents of the alimen- 
tary canal transferred to the blood hinder the proper assimilation of 
phosphates, and thus serve to initiate the rickety process in the bones. 
For this reason children should be nursed at regular intervals, and the 
milk must be neither excessive nor deficient in quantity, neither too 
rich nor too thin. Acidity should be prevented by the addition of soda 
or lime-water. 

At the time of weaning it is necessary to continue the use of food 
that is principally digested in the stomach, since food that is digested 
in the intestines parts with its calcareous salts, and they are precipi- 
tated and voided with the stools. For this reason the diet should con- 
sist of milk, soft boiled eggs, meat-juice, and thoroughly cooked oat- 
meal gruel ; at a later period, fish, broths, bean soup, and preparations 
of whole meal, all of which are rich in phosphates, may be added ; cod- 
liver oil is also useful at this period, if it can be properly digested. 

In the treatment of rickets salt baths, friction of the skin, gentle 
massage, and an outdoor life, are all of great importance. 

The pharmaceutical treatment of rickets consists in the administra- 
tion of phosphorus, of which one-sixth of a grain may be dissolved in 
three ounces of cod-liver oil ; of this mixture fifteen drops may be given 
three times a day. A more agreeable preparation is the following : 

R. — Phosphorus. gr '. 

01. amygdal. dulc JJijss- 

Pulv. gum acacia?, \ . 

Syr. simpl. J ' ' * ' 3J b • 

Aq. destill q. s. ad ^iij. — M. 

S. —Give one to four teaspoonfuls in divided doses, each day, according to the 
age of the patient. 

The syrup of iodide of iron, and small doses of nux vomica or of 
gentian, have been recommended. The salts of calcium are also useful 
in many cases ; it is generally sufficient to sprinkle a small quantity of 
powdered calcium phosphate upon the food of the patient. An emul- 
sion of the lacto-phosphate of calcium with cod-liver oil frequently 
gives a good result. The syrup of the lacto-phosphate of calcium should 
be generally avoided, since the continual administration of syrups tends 
to aggravate the acidity of the alimentary canal. For the same reason 
the syrup of the hypophosphite of calcium is objectionable, but the 
powdered salt itself may be given with advantage in a freshly prepared 
aqueous solution. 



CHAPTER II. 

OSTEOMALACIA. 

Osteomalacia is a disease that is characterized by decalcification and 
softening of the bones. It is a malady of adult life and old age, in this 
respect differing from rickets, which is manifested only during early life 



OSTEOMALACIA. 629 

as an interference with the formative processes by which the skeleton 
is evolved. Osteomalacia attacks and destroys bones that have been 
fully developed and far advanced in age. 

Symptoms. Osteomalacia commences insidiously, with vague pains, 
especially in the region of the vertebral column and pelvis. These 
pains are usually referred to rheumatism or neuralgia, but careful 
examination is unsuccessful in localizing them upon the muscular or 
peri-articular tissues of the body. The pain is dull and continuous, and 
is augmented by long-continued standing or sitting without change of 
position. These pains are not excited by pressure, yet pressure is 
usually painful when applied to the seat of suffering. They are gener- 
ally augmented by the warmth of the bed at night. After a time 
deformity becomes manifest at the seat of pain. When the disease 
occurs during pregnancy, pain is experienced in the pelvis, and is 
aggravated by walking, standing, or sitting. In advanced cases the 
promontory of the sacrum is pushed forward, and the lateral portions 
of the pelvic cavity approach each other so that the symphysis pubis 
projects strongly in front. The act of parturition is of course rendered 
difficult, if not impossible, by these deformities. 

Among old people the disease is usually manifested in the spinal 
column and in the thoracic walls. The stature of the patient progres- 
sively diminishes ; the spine becomes bent either antero-posteriorly or 
laterally. As the natural curvatures become exaggerated, curves of 
compensation are developed in other portions of the vertebral column. 
The sternum projects forward ; the shoulders become unequal ; the head 
bends forward so that the chin approaches the breastbone ; the bones 
of the extremities and the shoulder-blades may also share in the process 
of disease. The distal phalanges of the fingers and toes sometimes 
become thickened and enlarged ; the cranial bones rarely suffer, except 
in the severest cases of puerperal osteomalacia. 

As the disease advances the bones are frequently fractured by the 
slightest cause, and their repair is exceedingly tedious and imperfect. 

It is obvious that as the disease develops the act of locomotion becomes 
increasingly difficult ; the movements of the heart and of the lungs are 
also impeded as the thoracic cavity undergoes deformation. 

Digestive disorders are frequently observed, and are supposed to 
exert a prejudicial influence in the causation of the disease. Dilatation 
of the stomach and excessive acidity of the alimentary canal are com- 
mon occurrences. Chronic diarrhoea, chronic bronchitis, and chronic 
nephritis, sometimes occur. 

The duration of the disease is variable, sometimes terminating life in 
a few months, though generally its course is prolonged for a number of 
years. When the disease commences during pregnancy it is liable to 
renewed aggravation during subsequent periods of pregnancy. Death 
results from marasmus, or from intercurrent diseases, such as pneu- 
monia, tubercular consumption, bedsores, etc. 

Etiology. The occurrence of pregnancy is the most powerful pre- 
disposing cause of osteomalacia ; old age occupies the second place. 

The occurrence of osteomalacia during pregnancy must be explained 
by the existence of an error of nutrition which derives the calcareous 



630 DISEASES OF NUTRITION. 

salts and other materials needed for the development of the : 
skeleton from the jsseous tissues of the mother. Nearly 90 per 
cent, of the recorded cases of osteomalacia have Consequently occurred 
among women : of these female patients. 75 per cent, had been preg- 
nant, and in 50 per cent, the disease commenced during pregnancy. 
Pro 1 : n and frequent ehUdbearmg are also favoring causes 

for th 'ornent of the 

It is supposed that the use of drinking-water that contains an 
insufficient amount of calcareous salts may favor the development of 
)steomalaci . especially among patients whose bygienie environment is 
defective. 

As might be expected, a parasitic explanation for the occurrence 
of the ;n conjectured, but for this there is no adei 

proof 

Pathological Anatomy. The changes manifested in the 1: 
ig the course of osteomalacia consist simply in the solution and 
removal of calcareous salts from the >sseoua framework. The cellular 
elements do not multiply, and the fundamental substance >sseinc 
the bone assumes a fibrillary appearance. It apparently underg ea 
hyaline defeneration, and does not yield gelatin when it is boiled. 
The marrow, however, is at first highly vasculai .. and its 

cells are considerably multiplied. At a later period the tissue becomes 
infiltrated with fat. 

The disease I I *nea c : ntain an rx sess : ■:' lactic acid, which also apj 
in the urine. The normal alkalinity of the blood is also considerably 
diminished. The percentage of the mineral constituents of the 
may be diminished from 54 to 20 per cent. 

the urine does not often contain an excessive amount of calcareous 

matter. Earthy calculi are sometimes found in the kidneys and in the 

Ler, but a large proportion of the phosphates is removed with the 

milk of the nursing mother, or find its way to the tissues of the 

embryo in cases of pregnancy. 

The which thus occurs is dependent upon the excessive 

nee of lactic acid in the bones : it is uncertain whether this acid is 
produced in the substance of the bone itself, or whether it is merely 
accumulated there after its formation elsewhere. Such accumulal 
mav be verv easily occasioned by defective oxidation within the tissues. 
This acid dyserasia interferes with healthy nutrition and leads to the 
solution and removal of earthy phosphates from the bones. This ex- 
planation is rendered still more probable by the fact that lactic acid, 
and other organic acids, are present in excessive amount in 
and it appears that osteomalacia may be exchanged for diabetes in the 
same person, if subjected to a change of environment from the damp 
and squalid conditions that favor osteomalacia. Under such cireum- 
■•:-s the osseous disease is arrested before glycosuria appears as a 
- _ ^uence of the persistence of the - i. It is probable, 

moreover, that th^- ffi is pains which are so frequently experienced 
by the victims of pulmonary consumption, and are accompanied by 
phosphaturia. are in like manner dependent upon a minor degree of 
malacia that is insufficient to produce softening and deform it 



OBESITY — POLYSARCIA. 631 

the bones. In the same way the occurrence of abnormal fragility of 
the bones may be explained. It is a matter of observation that in all 
these cases, not only are the calcareous salts reduced in quantity, but 
the nitrogenous and fatty constituents of the skeleton are also greatly 
diminished, and are replaced by an increased amount of water. 

Prognosis. The prognosis is exceedingly unfavorable. Recovery 
is a very rare incident, though life may be prolonged for a considerable 
number of years. 

Treatment. The treatment of osteomalacia is principally addressed 
to the improvement of the digestive functions. The food should be 
abundant and digestible, consisting largely of eggs, milk, and whole 
meal flour. The circulation should be improved by friction of the skin, 
massage, salt baths, and gentle exercise. These methods will accom- 
plish better results than can be obtained from cod-liver oil, phosphorus, 
and the ordinary tonics. The occurence of the disease during preg- 
nancy may render necessary the operation of Cesarean section. Re- 
cently the ovaries have been removed with favorable results in the way 
of preventing pregnancy, and arresting the progress of the disease in 
cases where it was already manifested. In certain cases the suppres- 
sion of the menses that follows the operation appears to exert a most 
favorable influence. 



CHAPTEE III. 

OBESITY— POLYSARCIA. 

Obesity is a condition of ill health characterized by an excessive 
accumulation of fat in the adipose tissue of the body, by which the 
function of the various organs is hindered, and finally rendered im- 
possible. This accumulation of fat is seldom distributed uniformly 
throughout the body ; sometimes it is excessive in one portion, and 
sometimes in another; it may greatly hinder the functions of a par- 
ticular organ, while others experience very little impediment. The 
visceral cavities rarely become overloaded with adipose tissue without 
a similar enlargement of the subcutaneous deposit, so that external 
corpulence may be generally accepted as sufficient evidence of an in- 
ternal burden. 

Among the internal organs that suffer from obesity the heart is the 
most important. Fat is deposited under the visceral pericardium, in 
the furrow between the ventricles, and around the roots of the large 
vessels. In an advanced stage of the disease the muscular fibres of 
the left ventricle are forced asunder by the fat that infiltrates the con- 
nective tissue. Pressure thus produced causes atrophy and fatty de- 
generation of the muscular substance. In this way the functions of 
the heart are rendered difficult, both by the external burden of fat and 
by the degeneration of the contractile tissue of the organ itself. In 



632 DISEASES OF NUTRITION. 

like manner the liver is frequently overwhelmed ; it suffers from the 
external pressure of the fat-laden epiploon and mesentery before the 
hepatic cells become infiltrated and finally incapable of function. 

In the normal condition the fat cells of the adipose tissue receive 
and store up a certain amount of fat that serves as a magazine from 
which is continually supplied the proper quantity of fatty matter that 
is needed for the healthy nutrition of the tissues ; in this respect the 
function of the adipose tissue is quite analogous to that of the glyco- 
genous tissue of the liver. This adipose tissue is encountered wherever 
there is connective tissue, excepting in the lungs, in the liver, spleen, 
kidneys, and encephalic organs. The physiological amount of adipose 
tissue is about one-twentieth of the total weight of the body. 

The supply of fat in the adipose tissue is normally recruited in part 
from the alimentary fat which enters the circulation, either in the form 
of an emulsion or in the form of glycero-phosphoric acid and soap. A 
portion of the fat is held in solution by the aid of the soaps that are 
formed by the union of the fatty acids with alkaline bases. The de- 
composition of fat into glycerin and fatty acids is effected by the action 
of the pancreatic juice and the bile. As glycerin is liberated, it enters 
into combination with phosphoric acid that has been displaced from the 
alimentary phosphates by the hydrochloric acid of the gastric juice. 
The resultant glycero-phosphoric acid and the soaps that are formed 
by the fatty acids are highly diffusible, and pass readily into the gen- 
eral circulation. The emulsified fats arrive at the same destination 
through the chyliferous passages and the thoracic duct. Conveyed to 
the tissues the glycerin and fatty acids are rapidly oxidized, while the 
more stable emulsified fats are stored up in the cells of the adipose 
tissue. 

Besides the source of supply that exists in the alimentary fats, a 
certain amount of fat is formed during the retrograde metamorphosis 
of the albuminoid constituents of the tissues. During this process 
albumin splits up into nitrogenous bodies like leucin, tyrosin, and other 
antecedents of urea, while the remainder contains no nitrogen and 
yields substances identical with fat and other compounds of carbon and 
hydrogen. In this way an animal that is fed upon albuminoid sub- 
stances alone may still grow fat. 

When fat enters the blood in quantity greater than can be held in 
solution by the soaps and alkaline salts a portion remains suspended 
in the circulatory fluid, presenting and giving to the blood an oily 
appearance, constituting what is termed liposmia. When the process 
of oxidation proceeds at the normal rate, the fats that are thus intro- 
duced are rapidly oxidized ; when introduced in excessive amount the 
oxygen that is active within the tissues cannot completely effect their 
oxidation, and the surplus fat accumulates in the adipose tissue and in 
the cells of the liver. When the processes of oxidation are exagger- 
ated by violent exercise or by fever, fat ceases to accumulate, and 
rapidly diminishes in amount. For this reason the excessive disap- 
pearance of fat is accompanied by a diminution of the staying power 
of the individual ; hence the lack of endurance that characterizes 
athletes, gymnasts, and champions who have been deprived of their 



OBESITY — POLYSARCIA. 63-3 

reserved force by overtraining that has caused the dissipation of their 
adipose tissue. 

Pathological Anatomy. The adipose tissue accumulates chiefly 
upon the anterior and lateral portions of the abdomen, about the loins, 
hips, breasts, neck, cheeks, and under the chin ; it is found in the 
flexures of the joints, upon the palms of the hands and the soles of 
the feet ; it is also abundant beneath the aponeuroses, between the 
muscles, even insinuating itself among their constituent fibres. It is 
sometimes difficult to reach internal organs, like the kidneys and the 
pancreas, which are completely buried in a mass of tallow. The 
stomach and the intestines are usually dilated ; the liver is enlarged, 
its borders are rounded, its color is pale, and oil oozes from incisions 
into its mass. The degree of fatty infiltration is, however, less than 
what exists in certain diseases that are attended by fatty degeneration 
of the organ. The hepatic cells are overladen with fat, but they are 
not in a condition of degeneration, and there is no accumulation of fat 
in the connective tissue outside of the hepatic cells. The secretion of 
bile is greatly hindered, so that the gall-bladder and the larger bile 
ducts are often empty or filled with mucus. 

When obesity is complicated with alcoholism or other diseases that 
invade the liver the hepatic cells undergo fatty degeneration (steatosis) : 
under these conditions the connective tissue exhibits a certain amount 
of sclerotic change ; the liver is then less soft and unctuous, and the 
outlines of the sclerotic meshwork can be traced among the groups of 
degenerated parenchymatous cells. If death has been occasioned by 
cardiac failure, the hepatic veins are distended with blood, and the liver 
presents the appearances that are characteristic of a stagnant circulation 
(nutmeg liver). 

The kidneys frequently escape without notable change. If death has 
been preceded by progressive asphyxia, their veins are distended with 
blood. In severe cases, especially when dependent upon alcoholism, 
the epithelium of the uriniferous tubules is frequently infiltrated with 
minute particles of fat. 

The connective tissue of the pancreas is more or less infiltrated with 
fat. The spleen exhibits little alteration. 

In female patients the uterus and its accessory structures are tightly 
packed into the pelvis, and fixed by layers of overlying fat. The 
mammary glands also become atrophied, in consequence of the enor- 
mous accumulation by which they are compressed. 

The great distention of the abdominal cavity crowds the diaphragm 
upward. The great increase of fat in the mediastinal spaces, and be- 
neath the pericardium and pleural membranes, diminishes the thoracic 
cavities, and hinders the proper expansion of the lungs. These organs 
are frequently in a condition of emphysema, and are engorged with 
blood when death has been preceded by symptoms of asphyxia and 
cardiac failure. 

The right ventricle of the heart is always more fatty than the left. 
The organ is burdened with masses of adipose tissue, and the myocar- 
dium is anaemic, pale, degenerated, and softened ; sometimes there is 
universal dilatation of the cavities of the organ ; sometimes the left 



634 DISEASES OF NUTRITION. 

ventricle is hypertrophied, while the right heart is dilated ; sometimes 
there is general atrophy. At an early stage of the disease the heart 
may be simply overburdened with fat, but as the disease progresses the 
spaces between the muscular fibres become infiltrated, and finally the 
muscular substance itself undergoes fatty degeneration. 

The blood presents an oily appearance ; as a consequence of the 
presence of minute particles of undissolved oil, the amount of fatty 
matter may be four or five times greater than in the normal condition. 
In the state of health the blood contains between one and two parts of 
fatty matter per thousand : but in obesity these substances may be 
present to the amount of between five and six parts per thousand. 

Symptoms. Obesity occurs more frequently among women than 
among men. It sometimes exists among infants and voung children ; 
in certain instances children less than five years of age weigh as much 
as men of ordinary size ; a case is recorded of a child who at ten years 
weighed 200 pounds. Among adults a weight of 200 to 220 pounds 
indicates for a person of medium height the first degree of obesity. A 
weight of 300 or 350 pounds constitutes the medium form of obesity. 
When the weight rises to a figure between 400 or 500 pounds, the dis- 
ease must be considered serious. There is recorded the case of a man 
who measured fifteen feet in circumference, and weighed 715 pounds ; 
and of one monster it is related that his weight lacked only twenty 
pounds of eleven hundred. 

The distribution of fat depends largely upon the habits of life and 
the sex of the individual. Women accumulate adipose tissue in excess 
about the shoulders and breasts. Sedentary people and great eaters 
exhibit enormous abdominal enlargement. In aggravated cases of the 
disease locomotion becomes difficult ; the various acts of life are rendered 
impossible without assistance, and finally the unfortunate victim is 
compelled to remain in bed, supported by pillows and cushions, since it 
is impossible to lie down on account of the difficulty of respiration. 

Sexual appetite rapidly diminishes and becomes finally extinct. 
When obesity occurs among young girls, menstruation is usually pre- 
cocious ; it is often irregular ; amenorrhoea and menorrhagia sometimes 
occur, and sterility is exceedingly common. 

Muscular power is greatly diminished, though sometimes special skill 
and dexterity have been cultivated by professional people — like musi- 
cians, artists, and gymnasts. Occasionally considerable intellectual 
power is manifested by very corpulent people, but generally the in- 
tellectual faculties are greatly impeded in their action. The victims of 
obesity sleep much, especially after eating. 

The occurrence of obesity interferes seriously with the movements of 
respiration and with the action of the heart. Such persons are quickly 
out of breath after any muscular exercise. This is due to the limited 
capacity of the thoracic cavity, and in certain cases it is aggravated by 
the diminution of luemoglobin in the red corpuscles. The number of 
these bodies is not diminished, but their capacity for oxygen is greatly 
decreased, hence the want of breath that is experienced by the patients. 

In about one-third of the cases the pulse is retarded ; in another 
third the pulse is feeble, frequent, and dicrotic. The heart is also 



OBESITY — POLY8AKCIA. 635 

enfeebled, and there is complaint of palpitation and dyspnoea upon the 
slightest effort. In about one-quarter of the cases among elderly sub- 
jects symptoms of arterio-sclerosis are apparent. The pulse is full and 
hypertrophied ; vertigo, dyspnoea, and asthma are not uncommon. In 
a small number of cases the pulse is feeble, frequent, intermittent, and 
irregular, and dyspnoea is almost intolerable. 

Various forms of hemorrhage, such as epistaxis, haemoptysis, and 
bleeding piles, are not uncommon among the obese. These are depend- 
ent in great measure upon fatty infiltration of the vascular walls. 

Two forms of obesity are readily distinguished. The first is char- 
acterized by plethora ; the face is red, the lips are blue, and upon the 
cheeks and nose the veinlets are distended with blood. The anaemic 
form is characterized by pallor, by murmurs in the large vessels, and 
by a tendency to syncope. In certain cases of combined obesity and 
chlorosis there is a congenital lack of development in the vascular sys- 
tem, so that the heart, lungs, liver, and arteries are insufficient for the 
distribution of blood to the relatively enormous body. In such cases 
the total amount of blood is less than normal, though its quality may 
conform to the proper standard. 

The process of oxidation in the tissues is depressed, and consequently 
the amount of carbonic acid that is discharged from the lungs is dimin- 
ished, and the temperature of the body is reduced. 

In the majority of cases the amount of urea is below the normal 
quantity. The phosphates are also diminished, but in certain cases 
the amount of urea remains normal, and sometimes it is increased. 

When the excessive accumulation of fat is due to the splitting up of 
albuminous substances, in connection with a deficient supply of oxygen, 
a portion of the nitrogenous refuse appears in the urine in the form of 
a modified albumin that is not dependent upon an inflammation of the 
kidneys, but rather upon the disordered condition of nutrition. Some- 
times, minute globules of oil make their appearance in the urine, and 
it is not uncommon to discover sugar in the urine. In certain cases 
this is due to the coexistence of diabetes, but sometimes it is dependent 
upon a disordered condition of the liver that hinders the transformation 
of the starch and sugar of the food into glycogen. In such cases the 
alimentary sugar passes directly into the circulation and is eliminated 
with the urine. 

Oxalate of calcium is very frequently present in the urine of obesity, 
because the reduction of oxidation renders it impossible to destroy the 
oxalic acid that enters, or is formed in, the tissues. For the same 
reason the volatile acids are not oxidized, and their elimination through 
the skin causes irritation of the sebaceous glands and of the integu- 
ment. Acne, eczema, intertrigo, and seborrhoea frequently occur. 
The perspiration is also copious, and is characterized by a disagreeable 
odor. 

The appetite is sometimes excessive, and obese patients have been 
known to consume enormous quantities of food and drink. Sometimes 
polyuria exists at the same time. In the majority of cases digestion 
finally gives way, the stomach becomes dilated, and the symptoms of 
acid dyspepsia (pyrosis, flatulence, acid eructations, and constipation) 



636 DISEASES OF NUTRITION. 

are manifested. Sometimes there is diarrhoea, and the feces may con- 
tain a large quantity of fat. 

Such excessive appetite, however, exists in less than half the cases. 
In about fifty per cent, of the patients the appetite is normal, and in 
about ten per cent, the daily quantity of food that is consumed is less 
than usual. 

Obesity is frequently accompanied by stagnation of the blood in the 
intestinal vessels. The muscular coat of the intestines becomes en- 
feebled, there is obstinate constipation, and haemorrhoids are developed. 
Varicocele and varicose enlargement of the veins in the lower limbs 
frequently occur. Similar laxity of the other non -striated muscular 
tissues of the body is very commonly observed whenever these dilata- 
tions of the veins exist. 

Etiology. Excess in eating and drinking has been noted by 
Bouchard in about forty per cent, of the cases of obesity ; in about 
thirty-seven per cent, there was a deficiency of exercise, but in twenty- 
eight per cent, more than ordinary exercise was taken ; and in ten per 
cent, the amount of food was below the normal quantity. The disease 
occurs rather more than twice as frequently among women than among 
men. 

The influence of heredity is quite remarkable. Nearly one-half of 
the cases occurred in the direct line of descent from corpulent ancestors. 
It is worthy of note that those hereditary influences which predispose 
to arthritic disease also favor the occurrence of obesity. In fact, the 
arthritic diathesis is characterized by a retardation of the molecular 
changes that are concerned in the processes of nutrition, so that its 
victims are predisposed to rheumatism, gout, gravel, biliary lithiasis, 
diabetes, asthma, acid dyspepsia, haemorrhoids, hemicrania, neuralgia, 
and eczema, a group of diseases that apparently depend upon a common 
cause. These diseases are frequently associated in the same subject, 
either at the same time or alternately, and their association may be traced 
through many successive generations. In like manner those forms of 
scrofula that are not associated with tuberculosis frequently manifest a 
tendency to the development of arthritic diseases. 

Obesity may be manifested at any time in the course of life. It is 
sometimes congenital ; in other cases it does not appear before the age of 
puberty ; and it may be delayed until the decline of life. 

The development of the disease is much more frequently occasioned 
by the excessive use of starchy and saccharine food than by the inges- 
tion of oily substances. Acid dyspepsia is another common cause of 
obesity ; excessive acidity of the contents of the small intestine hinders 
the action of the pancreatic juice, and the fats are consequently absorbed 
in the form of an emulsion instead of being decomposed into glycerin and 
fatty acids. These emulsified fats largely escape oxidation, and are 
stored up in the adipose tissue. Sedentary habits and lack of exercise 
prevent the assimilation of sufficient oxygen, and therefore favor the 
accumulation of unoxidized fats in the tissues, thus contributing to the 
development of obesity. In like manner the continued use of alcohol, 
even in small quantities, hinders the process of oxidation and favors 
the accumulation of fat. For these reasons people who live in the open 



OBESITY — POLYSARCIA. 637 

air without taking much exercise, and who consequently have excellent 
appetites which they indulge freely, present some of the finest examples 
of obesity. Among these, stands preeminent the old-time coachman, 
whose life alternated between a state of immovability upon his coach- 
box, and a condition of equal inertia upon the oaken settle of a bar- 
room, behind a table covered with appetizing viands that were washed 
down with copious draughts of strong ale and porter. These drinks, 
besides alcohol, contain dextrine and sugar, substances that are ad- 
mirably calculated to promote the development of adipose tissue. 

Small and frequent losses of blood favor the development of obesity 
and anaemia. For this reason many women manifest the disease in 
greater or less degree. The impoverished blood becomes incapable of 
transporting a sufficient amount of oxygen ; the process of oxidation is 
consequently retarded ; and obesity accompanies the establishment of 
anaemia. In like manner pregnancy, disturbances of menstruation, 
and lactation, frequently occasion, the disease. This is especially true 
when the patient leads a sedentary life and indulges an appetite for 
alcoholic beverages and sweets. 

The period of convalescence after various infective diseases is some- 
times marked by a tendency to obesity. This is probably due to the 
concurrence of conditions that have been already noted. In many 
cases, doubtless, nutrition is profoundly influenced by the secretions of 
the infective microorganisms by which the tissues have been invaded. 
Among these perversions of nutrition obesity finds its place. 

Among the predisposing causes of obesity, a retardation of the pro- 
cesses by which fats are oxidized in the tissues has been made promi- 
nent. In addition to this must be mentioned the fact that the disease is 
not unfrequently occasioned by the operation of causes that favor the 
production of fat within the tissues. This may depend either upon a 
redundancy of oily substances in the food, or upon the direct pro- 
duction of fat through the splitting up of albuminoid molecules. It 
has been incontestably demonstrated that fat can be accumulated from 
a diet composed entirely of lean meat. It has also been shown that a 
diet of starch and sugar favors the development of fat, provided a cer- 
tain amount of albuminoid matter be also supplied to the tissues. 
Under such circumstances the carbohydrates are oxidized, while the 
albuminoids are split up into fat and into simpler nitrogenous com- 
pounds by which the integrity of the tissues is maintained, and the 
adipose tissue is increased. For this reason a diet of potatoes, bread, 
or corn-meal, favors the. accumulation of fat, since those substances 
contain not only starch but also albuminous constituents. 

The influence of water upon the development of fat has been exten- 
sively discussed, and a considerable variety of opinions has been 
expressed. In the opinion ot certain physiologists the copious use of 
water does not contribute to the development of fat, while others main- 
tain the opposite doctrine. It appears to be probable that water alone 
is without special influence, but when it is diluted with alcohol, and 
when it is reinforced with sugar and dextrine, it may contribute largely 
to the growth of corpulence. 

In many cases disorders of the nervous system appear to favor the 



638 DISEASES OF NUTRITION. 

development of obesity. Hysterical patients not unfrequently exhibit 
considerable excess of adipose tissue. The influence of neuralgia in the 
production of local accumulations of subcutaneous fat has been fre- 
quently cited. The corpulence that is sometimes noted after a paralytic 
stroke may be probably explained by the enforced change of habits 
from an active life to a sedentary mode of existence. 

Treatment. From time immemorial the importance of moderate 
diet and abundant exercise have been recognized. By the exclusion of 
fats and starch from the food, and by a large reduction of the amount of 
liquid that is permitted, the bodily weight can be rapidly diminished ; 
but with a diet thus restricted a tendency to lithiasis is very frequently 
manifested, and the patient suffers from hepatic or renal colic. This is 
one of the chief defects of the Banting method for the cure of obesity. 
Ebstein recommends three meals a day, of which breakfast is limited to 
one cup of black tea. without milk or sugar, and two ounces of well- 
buttered toast ; dinner in the middle of the day, consisting of shin- 
bone soup and four to six ounces of fat meat well boiled or roasted and 
served with gravy ; peas, beans, and cabbage in moderation ; dessert 
to consist of salads, fresh fruit, dried fruits without sugar, light wine in 
moderation, and black tea without milk and sugar ; for supper, a cup of 
black tea without milk or sugar, an egg, or in its place a little fish, ham, 
or other fat meat, an ounce of well-buttered bread, a little cheese or 
fresh fruit. The use of fats is allowed, but the carbohydrates are to 
be avoided. Oertel and others have recommended a similar regimen. 
Dujardin-Beaumetz insists that a diet thus restricted is insufficient for 
healthy nutrition. When the different organs of the body have not 
undergone degeneration the patient is permitted to drink about half a 
pint of liquid with each meal. Wine, if taken, should be very light, 
and diluted with Yichy or other alkaline waters. If it appear unde- 
sirable thus to dilute the gastric juice, the patient should be directed to 
abstain from drink at meal-time, and he may be permitted, two hours 
after each meal, to drink a pint of weak tea without sugar. Strong 
alcoholic beverages and beer are forbidden. Sometimes a little black 
coffee is allowed at the close of the morning meal. Soups are not 
allowed, but eggs, fish, meat, fresh vegetables, and fruits that are not 
too starchy are permitted. Pastry is forbidden. Bread should con- 
sist largely of crusts ; a favorite form is furnished by those slender 
rolls in which the crust forms the most considerable portion of their 
substance. Breakfast consists of three-quarters of an ounce of such 
bread, an ounce and a half of cold meat, and a cup of weak tea with- 
out sugar ; lunclieon, an ounce and a half of bread, three ounces of 
meat, or two eggs, the same quantity of fresh vegetables, salad, half an 
ounce of cheese, and fruit as desired; dinner in the evening, without 
soup, an ounce and three-quarters of bread, three ounces of meat, and 
other articles as at luncheon. Bouchard bases the treatment of obesity 
upon the condition of the urine. When the nitrogenous excreta are in 
excess, the amount of albuminous food should be reduced. When the 
urine exhibits a deficient quantity of urea the quantity of food should 
first be diminished, and then increased during the period of convales- 
cence. In all cases the quantity of fat, starch, and sugar in the food 



OBESITY — POLYSARCIA. 639 

should be five times the amount of nitrogenous nutriment. The quan- 
tity of fat should be somewhat reduced, so as to avoid any unoxidized 
surplus; and for the same reason the quantity of sugar should be 
limited, while the vegetable acids may be increased by giving fruits 
and fresh vegetables that contain organic salts of potassium, by which 
the process of oxidation is facilitated. Vinegar and other free acids 
are to be avoided, since their excessive use produces emaciation by 
destruction of the calcareous framework of the cells. Acids in small 
quantities aggravate obesity by diminishing the alkalinity of the body, 
but when combined with potassium the resulting salts favor oxidation 
and the destruction of fat. For the same reason food should not be 
taken too frequently or abundantly, and the patient should actively 
exercise his muscles before meals. When, however, urea and phos- 
phates are eliminated in excess, the processes of oxidation should not 
be unduly stimulated, and wine may be allowed. 

In order to promote nutrition the trophic functions of the nervous 
system must be aroused by agreeable occupation, travel, and other 
modes of intellectual excitement. Stimulation of the skin by friction, 
hydrotherapy, and massage yield favorable results. The function 
of the liver must be regulated, in order to avoid constipation and to 
favor intestinal digestion. Carlsbad water and similar mineral waters 
which contain the carbonate and sulphate of sodium favor the assimila- 
tion and oxidation of fats. In the same way bicarbonate of sodium, 
liquor potassse, and small quantities of soap are useful as aids to the 
oxidation of fat. Warm baths, taken at a temperature of about 100° F. 
for a half-hour or longer, raise the temperature of the body, accelerate 
the absorption of oxygen, and promote the elimination of carbonic 
acid. 

In the majority of cases it is well to commence the treatment by 
reducing the quantity of food, still preserving the proper proportion 
between its nitrogenous and its carbonaceous constituents. Milk and 
eggs furnish the best diet for this purpose. The patient should take 
for twenty days in succession not more than half a pint of milk and one 
egg every three hours during the waking portion of the day. No other 
food or drink should be allowed. Under this treatment the bowels 
become constipated, and require gentle laxatives or enemata. At first 
this restriction of the diet causes sensations of faintness, weakness, and 
sometimes dizziness, but in a short time these unpleasant symptoms 
disappear, and the disagreeable consequences of obesity rapidly 
diminish. At the end of three weeks the diet may be varied and 
gradually increased in accordance with the schedule previously quoted. 



640 DISEASES OF NUTRITION 



CHAPTEE IT. 

SACCHARINE DIABETES— DIABETES MELLITUS. 

Diabetes is a general constitutional disorder, accompanied by per- 
sistent glycosuria, and usually characterized by an excessive discharge 
of urine, inordinate hunger and thirst, and progressive exhaustion. 

Symptoms. Saccharine diabetes commences in an insidious manner, 
so that only after a considerable period of time are the symptoms of 
disease sufficiently pronounced to excite attention or suspicion of their 
significance. In many instances the nature of the disorder is acciden- 
tally revealed through examination of the urine for some purpose discon- 
nected with any idea of therapeutical treatment, as in cases of exami- 
nation for life insurance which bring to light an unsuspected diabetes. 
In many instances the excellent appetite of the patient has quieted all 
apprehension of any other disorder than a trifling constipation ; every 
meal is a source of satisfaction, and copious draughts of liquid are en- 
joyed with a gusto that is ascribed to the season of the year, or to the 
heat of the weather. Gradually, however, strength begins to fail ; 
thirst increases ; the mouth becomes dry : urine flows frequently and in 
greater abundance ; and as it dries upon the clothing it leaves behind a 
white powdery deposit that arouses the curiosity of the victim. Some- 
times there is an excessively annoying balanitis, or an intolerable itch- 
ing about the vulva ; the skin becomes dry through the suppression of 
perspiration ; the nails are brittle, and sometimes fall from the fingers 
and toes without any apparent cause ; obstinate itching eruptions of a 
lichenous character appear upon the surface of the body ; boils, car- 
buncles, and gangrenous degeneration of the skin may occur ; the sexual 
appetite disappears ; the power of vision becomes enfeebled ; emaciation 
progresses ; or, if bodily weight be not diminished, muscular energy 
and the power of locomotion are greatly reduced. In this condition 
the patient gradually fails, and finally dies, either from exhaustion, or 
in a condition of coma, or as a result of various complications. 

The mode of invasion is exceedingly variable, and so insidious is the 
advance of the disease that it is usually impossible to fix the date of its 
origin. When full} 7 established, the concurrence of polyuria, glyco- 
suria, excessive thirst, ravenous hunger, emaciation or exhaustion, con- 
stitute the most conspicuous and characteristic symptoms of the dis- 
ease. 

Diabetic urine is pale and opalescent : it exhales a sweetish, fruity 
odor, and when it contains from three to four per cent, of sugar its 
taste is unmistakably saccharine; the specific gravity is variable and with- 
out great diagnostic significance, though it is usually raised beyond the 
normal figure when the quantity of liquid is not inordinately increased 
by polyuria : its acidity is excessive, and is itself often a source of irri- 
tation and inflammation of the urinary organs, though such accidents 



SACCHAKINE DIABETES — DIABETES MELLITUS. 641 

are more frequently determined by fermentation of the highly saccharine 
urine. 

The presence of sugar in the urine does not by itself determine the 
existence of diabetes, since it may occasionally appear in the urine 
during the course of various maladies and intoxications of the body. 
Only when 'glycosuria exists as a permanent symptom, or when the 
amount of sugar that is voided during each successive period of twenty- 
four hours surpasses the quantity that is daily formed by the liver in 
health (3000 grains), can the existence of genuine diabetes be affirmed. 
The persistence of glycosuria is, however, the most important symptom, 
for though immense quantities of sugar are sometimes voided, in many 
cases the amount is comparatively insignificant. The urine that is 
passed during the period of digestion is especially rich in sugar, but 
during the later stages of the disease the morning urine contains the 
largest amount, formed at the expense of the tissues of the organism 
during the night, when the processes of disintegration are most active. 
The occurrence of intercurrent diseases, or of slight disturbances of the 
alimentary canal, is frequently followed by temporary disappearance 
of the urinary sugar, a fact that must not be forgotten in estimating the 
importance of such an incident. 

The quantity of urea is often increased during the advance of the 
disease, though it is greatly diminished during the period of terminal 
cachexia ; this increase must be referred in part to the excessive appe- 
tite of the patient, and in part to the increased disintegration of the 
nitrogenous elements of the tissues. 

The waste of the albuminoid elements is accompanied by a corre- 
sponding discharge of phosphates with the urine ; this process is but 
slightly influenced by the excessive appetite of the patient ; it is prin- 
cipally controlled by the rate of destructive metamorphosis in the nitro- 
genous constituents of the body. The elimination of urea and of phos- 
phates is not always uniformly parallel ; sometimes one substance is 
in excess, while the other is present in normal quantity ; sometimes the 
excess of phosphates alternates with that of sugar. It is supposed that 
the hrittleness of the bones and their liability to fracture which is some- 
times observed during the course of diabetes, can be explained by the 
excessive removal of phosphates from their substance. 

Albuminuria is frequently associated with glycosuria in the course 
of diabetes. In the later stages of the disease, and in certain special 
cases, it is the consequence of changes in the structure of the kidneys, 
but in the majority of instances the amount of albumin is very insignifi- 
cant, and Can only be detected by the most delicate tests. This form of 
albuminuria is frequently transient, and is accompanied by the char- 
acteristic signs of renal disease ; it is in such cases an evidence of 
depraved nutrition, and it is among this class of patients that diabetic 
phthisis is encountered. 

Uric acid is frequently present in excess during the course of 
diabetes ; this exaggerated excretion often precedes the appearance of 
glycosuria, and is one of the evidences of the relationship that exists 
between diabetes and gout. 

Diabetic poh/uria is characterized by frequent and excessive dis- 

41 



642 DISEASES OF NUTRITION. 

charge of urine, especially at night ; the total amount that is voided 
during twenty-four hours varies from two to twelve or fifteen quarts : 
it varies according to the degree of thirst that is experienced. In 
severe cases the patient is consumed by an imperious desire for drink ; 
the mouth is dry and sticky: the tongue is frequently smooth and red; 
the whole cavity of the mouth and pharynx appears slightly inflamed; 
the saliva is acid between meals, and sometimes contains sugar or lactic 
acid ; the gums are softened and bleed easily ; the teeth decay and fall 
from their sockets as a consequence of periostitis : thirst is most intense 
during the night and when the diet is rich in starch ; it is diminished 
by flesh food. 

The excessive hunger that is manifested by many diabetic patients 
is the consequence of the loss of sugar, urea, and salts. In certain 
cases the appetite is voracious, requiring each day not less than fifteen 
or twenty pounds of food for its complete satisfaction. Sometimes 
there is much suffering from gastralgia when the stomach is empty, 
and the pain can be relieved only by a hearty meal ; in many such 
cases the stomach becomes considerably dilated, and the symptoms of 
catarrhal dyspepsia serve to aggravate the condition of the patient. 

The acidity of the gastric juice is variable ; in the later stages of 
the disease, when the gastric glands have undergone atrophy, there 
may be permanent absence of free hydrochloric acid ; when the appe- 
tite is ravenous this acid is present in excess. 

The bowels are habitually constipated by reason of the excessive 
discharge of water through the kidneys, and as a consequence of the 
reduction of bile which accompanies the general diminution of secre- 
tion throughout the body. Sometimes, however, diarrhoea occurs as a 
consequence of overloading the stomach, or under the influence of 
various nervous disturbances. 

In the majority of cases the amount of perspiration is diminished 
by at least one-half; occasionally it is profuse, acid, and saccharine. 

The presence of sugar serves to irritate the skin, and to favor the 
occurrence of itching eruptions, such as pruritus, erythema, psoriasis, 
herpes, eczema, lichen, and xanthoma. Many cases of symmetrical 
cutaneous oedema and erythema may be referred to peripheral neuritis, 
which especially involves the vasomotor nerves. 

Boils, carbuncles, and gangrene are not uncommon incidents in the 
course of diabetes. The saccharine liquid with which the tissues are 
bathed affords a favorable medium for the multiplication of the micro- 
organisms of inflammation, suppuration, and putrefaction. For this 
reason the genital organs and cavities are frequently invaded by in- 
flammation, ulceration, and gangrene. 

The temperature is usually subnormal, and intercurrent febrile con- 
ditions are not accompanied by as considerable an elevation of temper- 
ature as is observed among other patients. This tendency is due to 
the reduction of the circulation through cardiac debility, to the exces- 
sive use of cold drinks, and to imperfect oxidation of the tissues. 

The absorption of oxygen falls below the normal level, so that in the 
later stages of the disease scarcely half the amount that is absorbed in 



SACCHARINE DIABETES — DIABETES MELLITUS. 643 

health is taken up by the tissues. A corresponding reduction in the 
liberation of carbonic acid and water is also observed. 

Notwithstanding the voracity of the appetite, the diabetic patient 
complains of muscular weakness, pain in the back, and cramps. These 
symptoms are principally due to the condition of the nervous system, 
of which all the functions are deteriorated. Symmetrical neuralgia is 
experienced in different parts of the body ; the sciatic nerves are the 
favorite seats of such pain ; it appears to be dependent, in many cases, 
upon the peripheral neuritis that is caused by the presence of an exces- 
sive amount of sugar in the blood. Various paresthesias, pruritus, 
pain in the joints and in the back of the neck, together with an exces- 
sive sensibility to cold, have been frequently observed. 

In many cases the tendinous reflexes are very much diminished or 
are totally abolished. In certain instances the patellar reflex is 
entirely absent ; this is an unfavorable symptom, and indicates great 
severity of the disease. Occasionally the patellar reflex is exaggerated, 
and in such cases the appearance of sugar in the urine must be referred 
to a lesion in the central nervous system, such as may be observed 
when in the course of tabes dorsalis, or multiple sclerosis, the floor of 
the fourth ventricle is invaded by the degenerative process. In fact, 
glycosuria may be anticipated whenever the fourth ventricle becomes 
involved in the diseases of the brain and spinal cord. 

Sometimes the symptoms of tabes dorsalis are manifested in the 
course of diabetes, constituting what is termed pseudo-tabes ; this dis- 
order may be distinguished from genuine tabes by its rapid develop- 
ment, and by its subsidence under the influence of treatment addressed 
to the amelioration of diabetic symptoms. Perforating ulcer of the 
foot, loss of the nails and of the hair, and other trophic disturbances, 
like the phenomena of pseudo-tabes, may be explained by the existence 
of peripheral neuritis. Occasionally, brief apoplectiform attacks are 
followed by hemiplegia ; and attacks of syncope, sometimes associated 
with vertigo, have been observed. Paralytic conditions are sometimes 
developed ; they are usually transient, and restricted to a single muscle 
or to a limited group of muscles ; ptosis and strabismus may be thus 
produced. Paroxysms of asthma and of severe neuralgia in the neigh- 
borhood of the heart sometimes recall the symptoms of angina pectoris. 
In certain cases the patient experiences paroxysms of invincible somno- 
lence which mark a tendency to the development of apoplectiform or 
comatose symptoms. Intellectual debility and other forms of mental 
disturbance are sometimes witnessed. 

The heart is affected in many cases. When the patient is vigorous 
and full-blooded, the organ may be hypertrophied, but in feeble indi- 
viduals it is usually dilated. When obesity exists, fatty degeneration 
and arterio-sclerosis invade the organs of circulation. In many cases 
endocarditis appears, apparently as a consequence of prolonged irrita- 
tion by contact with blood that is overcharged with sugar ; it is always 
a dangerous symptom. 

The odor of the breath is frequently perverted so that it resembles 
the odor of rotten apples. 

Lobar pneumonia frequently occurs, and is an element of great 



644 DISEASES OF NUTRITION. 

danger. A fibrinous pneumonia accompanied by dilatation of the 
bronchi, copious purulent secretion, and induration of the pulmonary 
parenchyma, has been observed. The various pulmonary and bronchial 
inflammations are sometimes followed by gangrene. The frequency 
with which pulmonary consumption is developed during the course of 
diabetes is worthy of note ; it commences insidiously, progresses rapidly, 
produces few and insignificant symptoms, but destroys the lungs in a 
most effectual manner. In many cases the existence of the disease is 
not suspected until a physical examination reveals the extent of its 
ravages. 

The function of vision is frequently disordered. Amblyopia, diplopia, 
paralysis of accommodation, dyschromatopsia. hemianopsia, retinitis, 
optic neuritis and atrophy, opacity of the vitreous humor, suppurative 
keratitis, iritis, irido-choroiditis, and cataract, may be enumerated 
among the diseases that invade the organs of vision. 

Otalgia, otitis, and deafness, sometimes result from diabetes ; and in 
like manner the senses of smell and of taste have been lost or perverted. 

The progress of diabetes varies with the age of the patient ; it is 
largely dependent upon the form of the disease : its course is very rapid 
among: children, with whom it usuallv occurs shortlv before the age of 
puberty : in such cases rapid emaciation is the rule, and deatli usually 
occurs within two years from the commencement of the disorder. 

The concurrence of diabetes and pregnancy is attended with great 
danger ; in one-third of the cases abortion occurs, and in half the cases 
delivery is followed by death from phthisis or coma. This grave form 
of diabetes differs widely from the transient glycosuria which is some- 
times observed among young women during the period of lactation. 

Excessive fatigue of mind and body favors the rapid progress of a 
dangerous form of diabetes. Art] kr 'it ic patients who manifest a tendency 
to corpulence frequently survive from fifteen to thirty years after the 
commencement of the disease : but when the function of pancreatic 
digestion fails, the patient becomes rapidly emaciated and succumbs in 
the course of eighteen months or two years. 

The two forms of diabetes thus indicated in the last paragraph stand 
in conspicuous contrast with each other. The arthritic variety is 
usually observed in persons who manifest a tendency to corpulence : it 
commences insidiously, the symptoms appear and disappear at intervals, 
and only after a considerable period are they fully confirmed and 
recognized : in manv cases the disease is hereditary. 

The malignant form of diabetes commences suddenly in the midst 
of apparent health : its course is rapid : the characteristic symptoms 
are conspicuous and unmistakable : emaciation and exhaustion are 
speedily developed : pulmonary consumption frequentlv appears, and 
death occurs at an early date. Heredity plays no part in this form of 
the disen- 

In certain cases diabetes follows the course of injur:/ or concuss 
involving the head and spinal column : the symptoms may be immedi- 
ately developed : though many months, or even years, may sometimes 
intervene before their appearance. When the symptoms appear imme- 
diate]}* after an injury, recovery generally occurs after three or four 



SACCHARINE DIABETES — DIABETES MELLITUS. 645 

months ; but when the disease is gradually developed after a consider- 
able interval, its course is protracted, and recovery seldom occurs. 

The fatal termination of diabetes is frequently caused by suppura- 
tion or by gangrenous processes that are dependent upon parasitic inva- 
sion. Pulmonary tuberculosis and diseases of the liver or kidneys are 
common causes of death. In many cases the final result is suddenly 
reached through the intervention of diabetic coma. 

Diabetic Coma. In rather more than half the cases of diabetes the 
disease terminates fatally, after the development of a form of coma 
which occurs under such circumstances and presents such characteristic 
symptoms that it deserves the special appellation which it has received. 
It usually originates suddenly after some form of fatiguing exercise ; it 
often follows a journey or other unusual mode of activity on the part of 
an enfeebled patient ; it is to be apprehended whenever the quantity of 
urine diminishes without a corresponding reduction in the amount 01 
sugar that is voided ; it may also follow an intercurrent disorder that 
exercises a depressive effect upon the nervous system ; it has been 
alleged that therapeutic measures which result in the reduction of 
glycosuria, favor the development of coma. 

The sudden cardiac collapse that sometimes overtakes diabetic 
patients must not be confounded with genuine diabetic coma. Col- 
lapse occurs as a consequence of fatty degeneration of the heart. It 
is characterized by the ordinary symptoms of cardiac failure, and is 
generally followed by death in the course of twenty-four or forty-eight 
hours, and it is a consequence of the general tendency to obesity and 
fatty degeneration which characterizes certain forms of diabetes. 

True diabetic coma is generally observed in the course of that form 
of the disease which is marked by rapid emaciation and cachexia. The 
development of coma is preceded by a peculiar, chloroform-like odor 
of the breath and of the urine. The urinary secretion is reduced in 
quantity, and contains less sugar than is ordinarily voided. Sometimes 
there is albumin present, and the liquid assumes a deep, port-wine color 
on the addition of perchloride of iron. Severe dyspnoea is also mani- 
fested, though respiration often exhibits no acceleration, and the patient 
is able to maintain the recumbent position. The physical signs afforded 
by auscultation are normal — in fact, the phenomenon is an evidence 
of a morbid state of the blood, by which the nervous system is excited, 
and the respiratory movements are deranged. 

In like manner the pulse shows very little disturbance, and the 
temperature falls gradually, perhaps after a transient moderate eleva- 
tion. The gastro-intestinal mucous membrane exhibits signs of disor- 
der which usually assume the form of nausea, vomiting, and diarrhoea. 
Sometimes the abdomen is distended and painful upon pressure, but no 
symptoms of inflammation or fever arise. 

Sometimes the attack is followed by a slight degree of exhilaration 
and exaltation of the mental faculties, but this is soon succeeded by 
somnolence and coma. Among young children convulsions have been 
sometimes observed. 

When coma has been fully developed, the patient lies motionless, 



646 DISEASES OF NUTRITION. 

with dilated pupils that react to the light ; the extremities are cold ; 
the surface of the body is cool ; the muscles are completely relaxed ; 
the temperature falls, and death occurs within three or four days. 
Occasionally the period of coma is preceded by headache, vertigo, and 
sensations like those of alcoholic intoxication ; alcohol in such cases 
has been found in the urine. 

A chronic form of diabetic intoxication has been described. It is 
characterized by a prolonged period of prostration, dyspnoea, distended 
abdomen, and a peculiar odor of acetone upon the breath. Sometimes 
these phenomena appear and disappear at intervals for some time before 
the final development of fatal coma. 

Pathological Anatomy. In the majority of cases the brain is 
diseased, but the morbid appearances are usually the consequence rather 
than the cause of diabetes. Among such lesions may be mentioned 
oedema, congestion, and thickening of the meninges ; anaemia, atrophy, 
and softening of the convolutions ; sclerosis, amyloid and colloid de- 
generation of the cerebral tissues. Cystic growths have been observed 
in various portions of the brain, but the tumors which have been occa- 
sionally observed in the bulb and fourth ventricle have doubtless been 
largely concerned in the causation of glycosuria. In certain cases the 
vessels of the bulb and of the brain are obstructed by embolic masses 
of glycogen which may have been concerned in the production of 
various nervous phenomena connected with the course of the disease. 
The spinal cord exhibits no characteristic lesions, but the cranial 
nerves are sometimes compressed by tumors which probably occa- 
sion certain phenomena of the disease. The spinal nerves are 
sometimes inflamed, probably as a consequence of the excessive pres- 
ence of sugar in the blood by which they are irrigated. The ganglia 
of the sympathetic nerves are sometimes enlarged and indurated. 

The blood is usually unchanged in appearance ; the number of red 
blood corpuscles is not diminished until a late period in the course of 
the disease ; the white blood corpuscles are often increased in number. 

The characteristic change in the blood is produced by the excessive 
presence of sugar ; its amount is subject to very considerable variation 
(0.35 gr. to 5.3 gr. per thousand). Urea and other nitrogenous 
excreta are frequently present in excess. Acetone is occasionally 
observed. 

The heart is pale and soft, or enlarged, or fat, in 50 per cent, of the 
cases. Sometimes pericarditis and endocarditis have been observed. 
The arteries frequently exhibit fatty degeneration or atheroma. The 
liver is frequently enlarged and fat. Cirrhosis is not uncommon, and 
pigmentary degeneration sometimes occurs. The spleen is usually 
small and soft ; its arteries exhibit hyaline degeneration. The pan- 
creas frequently exhibits more or less complete atrophy, which is 
sometimes the consequence of sclerosis of the connective tissue ; in 
certain cases it is the result of obstruction of the excretory ducts 
by calculi ; in other cases cysts are produced by dilatation of the 
obstructed ducts. Compression of the pancreatic duct by any form of 
tumor or exudation may result in atrophy of the organ, and in the 
development of malignant diabetes characterized by rapid emaciation 



SACCHARINE DIABETES — DIABETES MELLITUS. 647 

and an early death. Mere obstruction of the pancreatic duct is not 
usually followed by glycosuria, but it is almost invariably observed 
when the suppression of secretion is due to perivascular sclerosis — a 
lesion that is equivalent to a total extirpation of the organ. The 
mucous membrane of the stomach and of the intestines frequently 
exhibits a condition of chronic catarrh. The lungs and bronchi are 
often inflamed, but more frequently they are the seat of tubercular 
infiltration. The kidneys are frequently diseased. In certain cases 
chronic nephritis exists as an accidental complication of diabetes, but in 
many instances the lesions are the direct result of the disease. Some- 
times the epithelium of the convoluted tubules and of certain portions 
of the straight tubules exhibits a granular degeneration similar to that 
of coagulative necrosis. In many other cases the epithelial cells of 
those portions of the uriniferous tubules that lie within the marginal 
zone are enlarged by infiltration with glycogen. 

The mucous membrane of the entire uriniferous tract is frequently 
found in a condition of chronic inflammation. Balanitis and vulvitis 
are not uncommon. 

Various cutaneous diseases are frequently developed during the 
course of diabetes. Among them is a species of lichen that resembles 
xanthelasma. Parasitic diseases, such as boils, carbuncles, phlegmons, 
and gangrene, are of frequent occurrence. In the eye, cataract is the 
most frequent lesion. Sometimes retinal hemorrhage occurs, and the 
retina or the optic nerve may undergo simple atrophy. 

Etiology. Differences of climate exert very little influence upon 
the occurrence of diabetes, yet there are localities in which the disease 
is encountered more frequently than elsewhere. This fact may gener- 
ally be explained by the existence of different modes of alimentation, 
and perhaps by the greater predisposition of certain families and races 
to arthritic disorders. The excessive use of saccharine and starchy 
food has been assigned as a cause of diabetes, but it may be more cor- 
rectly stated that every form of habitual excess in the matter of diet 
creates a predisposition to diabetes through the defective nutrition that 
is thus produced. For this reason, the excessive consumption of meat, 
especially when taken together with copious draughts of beer and wine, 
is a fruitful cause of disorder which may culminate in diabetes. Such 
a predisposition is also favored by sedentary habits and insufficient 
muscular exercise. Hereditary influences are as evident in this con- 
nection as they are in other diseases of nutrition, like obesity, gout, 
rheumatism, lithiasis, asthma, eczema, and hemorrhoids. The disease 
is also not uncommon among the members of neurotic families in which 
mental derangement, epilepsy, paralysis agitans, exophthalmic goitre, 
and hysteria have been observed. The coexistence of obesity and 
diabetes has been frequently noted. The influence of sex is quite insig- 
nificant, but the predisposition of age is well marked ; the disease most 
frequently occurs during the period between fifty and seventy years. 

The exciting causes of diabetes are frequently found in acute and 
chronic diseases of the nervous centres, tumors, and injuries, princi- 
pally those which involve the fourth ventricle. 

Diabetes may be excited by psychical causes, especially by those of a 



648 DISEASES OF NUTRITION. 

depressing character ; disappointment, grief, and failure are frequent 
causes of the disease. The infective diseases, disorders of the hepatic 
function, and other derangements of the digestive organs, are some- 
times followed by diabetes. 

Diagnosis. Many cases of diabetes remain for a long time unsus- 
pected, by reason of the absence of the conspicuous symptoms — polyuria, 
thirst, and voracious appetite. Unless the urine of invalids be uniformly 
and frequently examined, many cases will escape detection. 

Numerous methods have been devised for the detection of sugar. Its 
presence may be determined by the well-known fermentation test, or by 
the use of the polariscope or saccharimeter. Numerous chemical tests 
have also been employed, but of these the most useful and clinically 
practicable is Fehling's solution. When properly prepared, each 
cubic centimetre of the solution is reduced by five milligrammes of 
glucose. The test may be applied by first boiling a drachm of the 
reagent in a test tube ; if it remain unchanged by ebullition it may be 
trusted for an accurate result. The suspected urine should then be 
poured slowly down the side of the inclined tube so that it may float 
upon the surface of the reagent. If then the urine contains a consider- 
able quantity of sugar, the surfaces in contact are defined by a greenish 
film that rapidly changes to a yellow, orange, and, finally, a red color, 
as the process of reduction extends itself. If but little sugar be present, 
the contents of the test-tube must be boiled for a few seconds. 

If albumin be present, reduction of the cupro-potassic solution will 
not be effected. Albumin must be first removed by coagulation or by 
precipitation with the subacetate of lead. Ammoniacal salts should 
first be removed by boiling the suspected urine with a little caustic soda, 
after which the test may be conducted as usual. Uric acid and the 
urates, when precipitated, should be removed by filtration, or better, by 
the addition of subacetate of lead, which, at the same time, eliminates 
albumin. 

The urine of patients who have inhaled chloroform or nitrous oxide, 
or who have taken chloral hydrate, reduces Fehling's solution, but the 
phemonenon is transient, and may be readily explained by reference to 
the previous history of the patient. 

Having determined the existence of glycosuria, it is necessary to 
ascertain whether it be a permanent condition, or whether it be merely 
the result of accidental excesses in the use of sugar-yielding food, or of 
an imperfect action of the digestive organs. Glycosuria of this char- 
acter exists only during the period of digestion, and the quantity of 
sugar is in exact proportion to the amount of saccharine and starchy 
food. The urine is, therefore, to be examined twice in the twenty-four 
hours ; one specimen being taken three or four hours after a meal, the 
other being secured at the time of rising in the morning. The con- 
dition of the digestive organs should also be ascertained, since the failure 
of digestion, and the existence of intestinal disorders, add greatly to the 
danger of the patient. The presence of albumin in the urine is another 
sign of danger. The amount of urea and other excrementitious sub- 
stances affords an accurate measure of the amount of tissue waste. It 
is also important to ascertain the hereditary tendencies of the patient, 



SACCHARINE DIABETES — DIABETES MELLITUS. 649 

since arthritic cases are usually less rapid in their course than those 
which exhibit a- tendency to emaciation and tuberculosis. The occur- 
rence of obesity, gout, lithiasis, etc., are also important in this con- 
nection, since their existence requires a special dietary and regulation 
of the habits of life. Diabetes that is dependent upon sedentary habits 
and excessive alimentation is less rebellious to treatment than when 
associated with hereditary arthritic tendencies. 

When the disease is dependent upon psychical or neurotic causes, or 
upon shocks and injuries affecting the nervous system, the prognosis 
and treatment should be largely influenced by these considerations, 
since the restoration of health to the nervous system may be followed 
by recovery from diabetes. 

Diabetic patients should be frequently weighed in order to ascertain 
whether the rate of tissue waste exceeds that of nutrition. In like 
manner the condition of the skin furnishes valuable information regard- 
ing the state of nutrition. The absence of the tendinous reflexes is an 
unfavorable symptom. Insomnia, disappearance of sexual appetite, 
loss of memory, failure of the special senses, are all important elements 
in the estimation of the case. Especially important is the examination 
of the lungs, since latent tuberculosis is not uncommon. 

Varieties of Diabetes. It is well known that in the lower animals 
glycosuria can be produced by puncture of the floor of the fourth ven- 
tricle, below the pneumogastric nucleus. It may also be produced by 
injuries involving the spinal axis at various points between the optic 
thalami and the lower extremity of the cord, the larger peripheral 
nerves, and the sympathetic ganglia. It is probable that many cases of 
diabetes are thus originated by local injuries of the central nervous 
system. 

Various toxic agents may also produce the discharge of sugar with 
the urine ; among these may be mentioned curare, carbon monoxide, 
chloroform, nitrite of amyl, methyldelphinine, hydrochloric and phos- 
phoric acids, turpentine, corrosive sublimate, nitrate of uranium, 
morphine, strychnine, hydrate of chloral, phloridzine, and lactic acid. 

The existence of glycosuria has been ascribed to the excessive use of 
sugar and starch, but since it has been shown that in a healthy con- 
dition of the digestive organs no special consequence follows the ex- 
cessive ingestion of such food, many physiologists have sought to explain 
the existence of glycosuria by assuming a chronic disorder of the 
alimentary canal, and of its associated glandular organs, the liver and 
the pancreas. This theory has received considerable support from the 
observation that extirpation of the pancreas in the lower animals pro- 
duces permanent diabetes ; but it does not explain those cases in which 
the pancreas remains healthy, and in which there is an obvious con- 
nection with disorders of the nervous system, or with the existence of 
arthritic tendencies. It has been conjectured that in health a ferment 
is furnished by the pancreas that transforms the glucose in the blood, 
and that the abolition of pancreatic function occasions diabetes through 
the absence of that ferment and the consequent overloading of the blood 
with unchanged glucose. 

Another hypothesis indicates the liver as the source of the disorder. 



DISEASES OF NUTRITION. 

Acorn ling to due explanation it is a .that the liver is rendered 

incapable of transforming the saccharine elements of the food into gly- 
_ ::. hence the blood becomes overcharged with glucose. 
A: ingto another hypothesis the liver is represented in a state of 
abnormal activity, producing an excessive amount of glycogen an 
pensing to the blood a mdingly inordinate quantity of glut 

The presence of a special ferment has been imagined to account for this 
trans: d of hepatic glycogen into glue:—. 

In certain cases it has been conjectured that the excess of glucose in 
the blood was due to an inor din ate t ■ " tionoj 

infec glucose 

Other hypotheses have been constructed upon the gas if a sup- 
'. /.re in the process in the organ- 

ism. PettenkofeJ and Yoit have suggested that when the albuminoid 
sonstituenfs of the body on ergc nndei normal conditions 

they furnish fat. but that when an insufficient quantity of oxygen is 
int, sugar is the resulting prod.;;:. Others have supposed that it 
is in the muscular substances that this imperfect oxidation takes place. 

stes results t : nsequence of the abnormal liberat: 
the elements of urea and sugar in the-- _ ha. A serious defect in 
this hypothesis : insists in the failure to recognize that diabetes is not 
alwav^ ss with a redundancy of nitrogenous elements in the 

urine. 

The accumulation of diabetic susrar in the blood has been ascribe 
erfect :':n and to the consequent red.; : the pro; 

:: nidation in the lungs. This hypothesis is weakened by the well- 
known fact that pulmonary consumption does not increase the amount 
: sugar in the urine, but is. on the contrary, followed by a reduction in 
its amount. Others have ascribed the accumul a gar in the 

blood to a suf [ — I :k of alkalinity in that fluid. Recently a con- 
jectural failure of energy on the part of the bl sei - been 
alleged as an explanation of various errors of nutrition. According to 
this hypothesis, if the blood serum is unable to assimilate hydrocar 

a leveloped : if incapable of assimilating f 
If. in like manner, ammoniacal niti _ a ..pounds cannot be in- 
fill be an excess of nr excreta in the urine. 
If albuminous compounds composed of the three former elementary 
substances cannot be transformed and assimilate lis the 
- 
Various authors have endeavored to reconcile these numerous hypoth- 
- - by incorporating them into a theory which re: _ s nu 
- of diabetes. Ace anting S< _en the minor for i 
are the result of a -fleet the 

normal transformation into _ _ :. of the lr inaceous elements 

- * 
of the food: while in the 8 i f ■ n* of the dis a 

not only the liver, but all the cells of the organism have lost their j 

-nose of the saccharine element of the blood. 

' remains undiscovered. It has 

bed to the action oi tone, which is undoubtedly present in the 
urine of patients whose breath and urine exhales an ethereal odor. 



SACCHARINE DIABETES — DIABETES MELLITUS. 651 

This substance, however, is frequently absent when coma appears, and 
it is often present when no signs of coma, or even of diabetes, are 
manifested. When administered in large doses it produces no poisonous 
effects. 

Diabetic coma has been ascribed to the action of diacetic acid, but 
the same objections that have been urged against the agency of acetone 
can also be brought to bear upon this substance. Oxybutyria acid has 
also been incriminated as the active agent in the production of coma, in 
the absence of sufficient ammonia to effect its saturation. 

These various and complicated hypotheses are sufficient evidence of 
our ignorance regarding the cause of diabetic coma It is, however, 
undoubtedly true that the condition is a symptom of auto intoxication. 
With these reservations, the term acetonemia maybe employed to indi- 
cate the complex and unknown causes of diabetic coma, just as the 
term urcemia is with corresponding ignorance employed to indicate the 
underlying conditions of renal coma. 

Treatment. The treatment of diabetes is dietetic and pharma- 
ceutical. 

Since the greater portion of the glucose in the blood is derived from 
saccharine and starchy substances, these elements should be excluded 
from the food of the diabetic patient. As substitutes for sugar, saccha- 
rine is often useful, but it frequently fails by reason of the dislike for its 
taste that is manifested by many patients. Glycerine is sometimes 
useful as a substitute for syrups. 

Fruits and vegetables rich in starch and sugar must be interdicted, 
viz.: potatoes, rice, preparations of flour and starch, beans, pease, 
lentils, chestnuts, turnips, radishes, grapes, plums, apricots, pears, 
apples, melons, figs, strawberries, cherries, gooseberries, raspberries, 
carrots, beets, onions, tomatoes, and asparagus. 

The following articles may be allowed : all kinds of butcher's meat, 
game, poultry, fish, oysters, clams, eggs, bacon, butter, fats, glycerine, 
spinach, chicory, cabbage, cauliflower, water cresses, lettuce and other 
salad plants, the different kinds of cheese, olives, nuts, unsweetened 
chocolate, and table salt, for which may be substituted tartrate of 
sodium, citrate of sodium, and phosphate of calcium. 

All beverages that contain sugar must be forbidden, viz.: lemonade, 
champagne, beer, cider, aerated waters, and milk, though skimmed 
milk has been recommended by Donkin as a beneficial article of diet ; 
its use, however, has not been attended with satisfactory results. 

Water and unsweetened coffee or tea may be allowed. Alcohol 
should be avoided on account of the injurious influence that it exerts upon 
the liver. Water may be allowed freely, since it assists in the elimina- 
tion of sugar, and if it be denied, the tissues are rapidly dehydrated. 

Bread made with gluten flour has been highly recommended, but it 
possesses the great disadvantage of being exceedingly distasteful, and 
liable to disorder digestion ; it also contains so much starch that it is 
inferior to potatoes as an article of diet. The carbonate of potassium 
which exists in the potato is a salt of great value as an aid to the assimila- 
tion of sugar, consequently the potato may be allowed in moderation as 



652 DISEASES OF NUTRITION. 

a substitute for ordinary bread. Cakes made of almond flour have 
been recommended. 

Simple glycosuria may be undoubtedly cured according to the 
method of Cantani by restricting the patient to a diet of meat and fat ; 
but in genuine diabetes such a restricted regimen is dangerous, since 
it occasions other disorders, and is supposed by many to create a pre- 
disposition to diabetic coma. Naunyn distinguishes three forms of 
diabetes : severe, moderate, and mild. In the severe form of the 
disease he recommends the method of Cantani, so long as the urine is 
not reddened by the addition of perchloride of iron, a symptom that 
indicates the imminence of diabetic coma. In moderate cases, after 
the disappearance of sugar under a flesh diet, he permits the use of 
eggs, milk, and a small quantity of bread. In mild forms of the 
disease greater liberty is allowed, but the urine must be continually 
watched, and the reappearance of sugar serves as a signal for greater 
caution in the matter of diet. He allows salads, string-beans, mush- 
rooms, pears, and apples. Beer is interdicted, and milk is only allowed 
when it does not increase the amount of sugar in the urine. In mild 
forms of the disease the daily ration consists of sixteen or eighteen 
ounces of meat, one to three ounces of bread, three or four ounces of 
vegetables twice a day, or an equal quantity of salad or apples. 

Active exercise, gymnastics, and massage are useful, since they aid 
the processes of oxidation in the organism. Warm baths should be 
taken three times a week. The clothing must be sufficient to prevent 
those chills that are so deleterious in cases of diabetes. All violent 
emotion must be avoided. Residence in a warm climate during the 
winter season affords favorable results. 

Pharmaceutical Treatment. The employment of alkaline 
remedies favors the process of oxidation within the organism. They 
are especially useful in recent cases, not too far advanced in years, who 
are vigorous, fleshy and plethoric, with a predisposition to arthritic 
diseases, and with urine rich in uric acid. Lime-water may be drank 
in large quantities by such patients. Magnesia, aqua ammonias (six 
drops three times a day), carbonate of ammonium (fifteen to eighty 
grains), bicarbonate of sodium (one and a half to three drachms), the 
citrate, tartrate, malate, and bicarbonate of potassium, sodium, or lithium, 
are all valuable alkaline salts ; hence the utility of Vichy water and simi- 
lar mineral waters. Bicarbonate of sodium is prescribed in cases of dia- 
betic coma by those who refer its manifestation to the excessive presence 
of acids in the tissues. When there is excessive production of urea and 
other nitrogenous excrementitious substances, alkalies and alkaline 
mineral waters diminish the amount of uric acid and sugar. Digestion 
improves, emaciated patients increase in weight, while the obese become 
less corpulent. When, however, the processes of oxidation are evi- 
dently depressed, alkaline remedies should be withdrawn. 

Opium and its derivatives are exceedingly potent to relieve thirst 
and hunger, and to diminish the amount of sugar in the urine. Codeine 
is recommended when the urine contains an inordinate amount of 
nitrogenous substances : it may be given in large doses if associated 
with strychnine. Belladonna is sometimes beneficial in recent cases, 



POLYURIA — DIABETES INSIPIDUS. 653 

but it is useless or often injurious in advanced cases, especially when 
the kidneys are diseased. 

Strychnine is useful in cases of debility, with enfeeblement of the 
visual, digestive, or generative organs. 

Laxatives and purgatives must be used with great caution, since they 
are liable to aggravate the existing glycosuria. 

Valerian diminishes thirst and polyuria. It is exceedingly useful 
when urea is eliminated in excessive amount. Arsenic and its salts 
have been frequently prescribed, but its use is often followed by disap- 
pointment. Iodine in the form of compound tincture has been recom- 
mended in doses of five to twenty drops before meals. Mercury is use- 
ful in syphilitic cases. Many other alterative remedies have been 
advised, such as the mineral acids, salicylate of sodium, carbolic acid, 
chloral, cocaine, astringents, ferments like yeast, diastase and pepsin, 
jambul, permanganate of potassium, peroxide of hydrogen, ozonized 
ether, inhalations of oxygen, etc. 

Remedies addressed to the nervous system have been employed with 
greater or less effect. Antipyrine, in doses of forty-five grains a day, 
causes a rapid reduction of glycosuria ; it is useless in tubercular sub- 
jects and in cases characterized by emaciation. The salts of quinia, 
especially the valerianate, have been recommended, in doses of three to 
ten grains a day. Bromide of potassium is indicated when the disease 
is associated with disorders of the bulb. Hypodermic injections of the 
fluid extract of ergot have also been recommended. Electricity has 
been employed in every possible way ; under its influence sugar some- 
times diminishes in the urine. Blisters and similar counter-irritants 
should be avoided, since they favor the occurrence of gangrene at the 
point of vesication. Thus treated, diabetes is curable, for a time at 
least, in fifty per cent, of the cases. 



CHAPTER V. 

POLYURIA— DIABETES INSIPIDUS. 

Diabetes insipidus is a constitutional disease characterized by an 
increase of urine, thirst, excessive craving for liquids, and accompanied 
by a variable proportion of the soluble constituents of the urine. In 
certain cases a small quantity of inosite, or muscle sugar, is contained 
in the urine. Sometimes there is an inordinate discharge of the nitro- 
genous excreta ; or the saline constituents may be increased in amount. 
Polyuria accompanied by albumin in the urine is due to the existence 
of interstitial nephritis, or may be the consequence of neurotic or 
arthritic conditions of the system. 

Symptoms. Simple polyuria is characterized by an increased dis- 
charge of urine. The desire to urinate recurs at comparatively short 
intervals, and the quantity of liquid that is discharged may be increased 



554 i : s z a s z ? . ■? y 7 r ?. : ' : ■:• v . 

from two- to tenfold. The water is light yellow or nearly colorle- 
acid reaction, speedily becoming nentral or alkaline after exposure to 
the air, with a specific gravity little above that of pore water, seldom 
reaching 1010. The solid constituents, though relatively diminished. 
are often absolutely increased. Occasionally sugar may be present for 
a brief period. The occurrence of albumin must be referred to actual 
inflammation of the kidney itself when its presence cannot be explained 
by the occurrence of hemorrhage or exudation in the course of the 
urinary tract. 

Eel rry thirst is a very common symptom in the course of 

polyuria. The mouth and throat are dry and sticky: perspirat 
diminished ; the temperature of the body is frequently subnormal : 
when the disease occurs in childhood the growth of the body is retarded 
and incomplete ; the appetite is irregular and perverted : gastric and 
intestinal digestion are usually disordered ; sometimes there is complaint 
of headache, dizziness, and diminished power of mental application : the 
sixth nerve is frequently paralyzed, and sometimes other cranial nerves 
are similarly affected ; the reflexes may be absent : in certain eases 
hemorrhage* are observed in the retina, and neuro- retinitis and at 
of the optic nerve occur : hemianopsia and amblyopia are not uncom- 
mon, but the occurrence of cataract is a rare event. 

In certain cases the nitrogenous constituents of the urine are greatly 
increased in amount. The symptoms closely resemble the dam 
picture of saccharine diabetes. There is increase in the quant- 
urine ; great thirst : voracious appetite : progressive emaciation ; dry- 
ness of the skin ; disturbances of the nerv system ; and frequently 
a rapid development of phthisis. The urine, however, contains 
sugar, but is heavily charged with urea. 

The disease usually commences gradually, but sometime- its 
sudden and abrupt- The amount of is > Less than the 

quantity of liquid that is drank, and it varies accordiug to the quantity 
of urea that is excreted. Its color is light yellow ; it is transparent and 
acid when it is voided, but soon becomes turbid and ammoniacal in con- 
sequence of the presence of mucus and epithelium thrown off from the 
urinary passages under the influence of the irritation excited by the 
excrementitious constituents of the fluid. The specific gravity varies 
from 1002 to 1050. The urinary sediment contains urates, uric acid, 
and sometimes oxalate of calcium. The daily discharge of urea varies 
from an ounce and a half to three ounces, with a considerable margin 
above and below these figures. Uric acid is seldom increased to any 
grea: ut the other nitrogenous excreta and the chlorides and 

phosphates are present in excess. A :nsiderable portion of due 

;ste must be referred to the inordinate amount of food that is 
consumed by many of these patieL> 

The patient complains of and progressive He be- 

comes gradually emaciated : the skin is pale and dry : the extremities 
are frequently livid by reason of the enfeeblement of the action of the 
heart : active exercise becomes impossible, and the temperature is fre- 
quently subnormal; headache is sometimes constant or of frequent 
occurrence : hemorrhage, pruritus, various perv- 3 of sensation in 



POLYURIA — DIABETES INSIPIDUS. 655 

the skin and mucous membranes, enfeeblement of the special senses, 
amblyopia with or without visible lesions, are sometimes present ; impo- 
tence is an almost constant symptom ; besides headache and insomnia, 
vertigo is often experienced, and the intellectual faculties are gradually 
extinguished ; sometimes tremors, spasms, or general convulsions occur, 
and death may be preceded by coma. 

The disease is usually chronic. The patient becomes emaciated, or 
finally dropsical. With the failure of appetite and of digestion the 
quantity of urea diminishes. Death may be occasioned by exhaustion, 
hemorrhage, gangrene, convulsions, coma, or by pulmonary consump- 
tion. In rare instances a cure has been effected by the intercurrence of 
some acute infective disease, or by the action of valerian or opium. 

Phosphatic diabetes (diabetes with phosphaturia) is generally de- 
veloped in the course of tuberculosis or of nervous disorder. The urine 
contains ammonio-magnesian phosphates ; and, if urates and oxalates 
are in excess, an iridescent film appears upon the surface of the liquid 
after standing for some time. In certain cases the disease is related to 
glycosuria. The patients present many of the symptoms of saccharine 
diabetes, and sugar may have been, or will be, found in the urine. The 
excessive elimination of phosphates has been ascribed to the splitting 
up of glucose within the organism into lactic acid, by which the salts 
are rendered more soluble and diffusible. The phosphatic diabetes that 
occurs among children and young people is frequently associated with 
oxaluria and with excessive discharge of uric acid. Sometimes traces 
of albumin are also apparent. These symptoms indicate the existence 
of a predisposition to gout or to gouty disorders. 

Oxaluria. Closely related with the different forms of diabetes is an 
error of nutrition which is characterized by the appearance of oxalate 
of calcium in the urine. The predisposition is frequently heredi- 
tary, and may either alternate or coincide with the appearance of dia- 
betes. The excessive use of aerated mineral waters and vegetables, like 
rhubarb, that contain oxalic acid, is frequently followed by an abun- 
dant discharge of the crystals of calcium oxalate in the urine. Patients 
who suffer with gout, tuberculosis, hypochondria, obesity, and a vora- 
cious appetite, are frequently subject to oxaluria. A small quantity of 
oxalic acid exists normally in the blood and is there destroyed ; but if 
an excess of calcium compounds are encountered in the circulation, the 
oxalic acid enters into combination with the calcium, and, held in 
solution by phosphate of sodium, is eliminated through the urine. In 
this way the normal excretion of oxalic acid is sometimes increased 
twenty- five-fold. 

The symptoms of oxaluria are characterized by great muscular 
weakness and nervous exhaustion. An acid and offensive perspiration 
accompanies slight efforts. The expression of the countenance indi- 
cates fatigue. The repose of night brings no increase of vigor, and 
during the day there is an invincible inclination to sleep. The breath 
is frequently offensive ; the skin is imperfectly nourished ; the hands 
tremble ; the phenomena of gastric neurasthenia are developed ; in 
severe cases there is rapid emaciation, in consequence of the excessive 



656 DISEASES OF NUTRITION. 

elimination of the calcic and phosphatic salts which are required for the 
maintenance of the tissue. 

Pathological Anatomy. Characteristic pathological changes are 
wanting in cases of diabetes insipidus. In certain instances the solar 
plexus has been found in a condition of degeneration with proliferation 
of its connective tissue. The kidneys are frequently enlarged and 
engorged with blood. The uriniferous tubules are sometimes dilated, 
and their epithelium may be in a condition of fatty degeneration, but 
these changes do not explain the symptoms, nor throw any light upon 
the nature of the disease. 

Etiology. Diabetes insipidus occurs two or three times more 
frequently among men than among women. It is a disease of middle 
life, though it sometimes originates in early childhood. The influence 
of heredity is well marked, and in certain families saccharine diabetes 
and simple polyuria alternate with one another. All forms of injury 
and disease of the nervous system may be followed by one or the other 
form of diabetes. The infective diseases and chronic intoxication with 
lead or alcohol may be followed by polyuria. In many cases the disease 
follows exposure to cold or to excessive heat, sudden chilling of the 
body, or any other form of shock or agitation of the nervous system. 

Diagnosis. The recognition of diabetes insipidus is easy, if the 
urine be subjected to chemical analysis. The disease must be distin- 
guished from saccharine diabetes and from chronic inflammation of the 
kidneys, principally by the results of urinalysis. From transient 
polyuria and from primary polydipsia it may be distinguished by the 
history of the patient, and by the fact that the excess of urine is im- 
mediately connected with the gratification of the desire for drink. 
Oxaluria, phosphaturia, and other varieties of urinary disorder, can only 
be recognized by urinalysis in connection with the characteristic 
symptoms of disordered nutrition. 

Prognosis. Recovery is an uncommon event, though the effects of 
treatment are frequently beneficial, if not permanent. The more rapid 
the emaciation and exhaustion, the more unfavorable are the prospects, 
though life is frequently prolonged for many years. 

Treatment. Simple polyuria is favorably influenced by the ad- 
ministration of antipyrine (fifteen grains every four hours). Lead and 
opium are less efficacious. The diet should be abundant and nutritious, 
and thirst may be relieved by acidulated drinks. Polyuria with an 
excess of nitrogenous waste requires an abundance of nitrogenous and 
starchy food. Quinine, arsenic, and codeine, especially when combined 
with strychnine, favor the resumption of healthy nutrition. Especially 
useful is valerian, of which the extract may be given in divided doses 
to the amount of an ounce in twenty-four hours. In syphilitic cases 
mercurial inunctions and iodide of potassium must be employed, but 
not otherwise. 

Phosphaturia must be subjected to various forms of treatment in 
accordance with its cause. When dependent upon tuberculosis the 
progress of infection must be retarded by the ordinary methods. In 
cases of nervous excitement, bromide of potassium and other nervines 
are useful. When there is an excessive production of acid in the system 



GOUT — ARTHRITIS URATICA. 657 

the alkalies and alkaline salts are useful. The food should be rich 
in phosphates, and for this reason whole-meal flour, eggs, and fish may 
be employed. Oxaluria requires attention to the diet, in order to avoid 
the introduction of oxalic acid with the food ; pie-plant and similar 
substances must be forbidden. Alkalies and alkaline salts favor nutri- 
tion, but calcium salts must not be administered. Moderate doses of 
sodium or potassium bicarbonate may be given with advantage for ten 
days in each month ; if administered continuously they may occasion 
the precipitation of earthy phosphates in the urine. Acid dyspepsia 
may be relieved by antiseptic remedies, such as naphthaline or the 
salicylate of bismuth. Dilute nitric or hydrochloric acids are useful 
for the relief of dyspepsia, since they diminish the excessive production 
of acid in the alimentary canal. 

The most favorable results, however, are secured by the improve- 
ment of nutrition that follows moderation in eating, copious draughts 
of hot water at bedtime, regular exercise in the open air, massage and 
gymnastics, sponging with salt water, change of residence and occu- 
pation, and all other methods that serve to tranquillize the mind and 
invigorate the body. 



CHAPTER VI. 

GOUT— AETHEITIS URATICA. 

So numerous and so varied are the manifestations of gout that it 
becomes impossible to furnish a brief and accurate definition that shall 
include all its varieties. It is always a chronic disease that persists 
during the whole of life when its origin is hereditary, and throughout 
the remainder of life when it has been acquired after birth. Its more 
conspicuous outbreaks are to be considered as exacerbations or exagger- 
ations of a morbid process by which the nutrition of the organism is 
retarded and perverted. It belongs to that remarkable group of dis- 
eases which may be associated either in the same individual or among 
members of the same family who have derived their morbid predispo- 
sition from a common source. Among these disorders are included 
certain cutaneous diseases — eczema, impetigo, erythema, urticaria, and 
the allied mucous inflammations of the respiratory tract ; also chronic 
acid dyspepsia, congestion of the liver, lithiasis, haemorrhoids, neural- 
gia, hemicrania, congestive headaches, acute, chronic, and muscular 
rheumatism, asthma, obesity, diabetes, and gout. These maladies all 
depend upon a peculiar retardation of nutrition that characterizes the 
arthritic diathesis. In the present state of our knowledge it is impos- 
sible to explain the manner in which are produced the different vices of 
nutrition that determine the appearance of diabetes in one patient, 
while another suffers with obesity, and a third becomes gouty. That 
these nutritive errors depend upon closely related and interchangeable 
causes seems to be indicated by the frequency with which a patient may 

42 



658 DISEASES OF NUTRITION. 

exhibit these disorders in succession, and also by the frequency with 
which they alternate with each other in the course of successive genera- 
tions. The gouty patient may become the victim of obesity, and the 
diabetic patient may give birth to gouty oifspring, etc. 

Etiology. Grout is a disease that is unknown among temperate and 
active races. It prevails among the wealthy inhabitants of large cities 
where luxury and self-indulgence are the favorite vices of the popula- 
tion. This tendency, which is based upon the excessive consumption 
of highly seasoned food, is greatly aggravated by the concurrent use of 
alcoholic stimulants, especially wine and beer. Active intellectual pur- 
suits, debauchery, and the exhaustion that results from the mad race 
after wealth and fame, contribute largely to undermine the system, and 
to excite the disease. For this reason it is far more frequently en- 
countered among men than among women. The sedentarv life of the 
luxurious female predisposes to biliary lithiasis and obesity, but rarely 
extends to the production of gout. 

Gout has been experienced at almost every period of life. It is, how- 
ever, more commonly observed during the period of active adult life. 
Hereditary influences exercise great influence upon the manifestation of 
the disease. About half the cases can be traced to a gouty ancestry. 
This tendency appears to be more frequently transmitted through the 
paternal line. According to the statistics collected by Bouchard, 
among the ancestors of gouty patients, obesity may be discovered in 44 
per cent. ; rheumatism, 24 per cent. ; asthma, 19 per cent. ; diabetes, 
eczema, and gravel, 12.5 per cent. ; biliary lithiasis, haemorrhoids, and 
neuralgia, 6 per cent. In only 12 per cent, of the cases was no hered- 
itary arthritic disease discovered. 

Among gouty patients themselves, obesity and dyspepsia have been 
noted in 31 per cent, of the cases ; gravel, in 28 per cent. ; hemicrania 
and eczema, in 19 per cent. ; neuralgia, in 12 per cent. ; acute and 
muscular rheumatism and asthma, in 19 per cent. ; chronic rheumatism, 
hemorrhage, and urticaria, in 6 per cent. ; diabetes, in 3 per cent. 

Besides the frequent association of the diseases thus mentioned, there 
is a notable relation between gout and the occurrence of cancerous dis- 
ease of the rectum and bladder. This complication is usually developed 
between the ages of fifty and sixty years. The ordinary gouty symp- 
toms by which the patient has been tormented disappear, and are 
replaced by the characteristic sufferings that accompany the evolution 
of carcinoma. 

Symptoms. A broad distinction must be maintained between the 
gouty diathesis and the manifestations of gout itself. Diathesis is 
merely a convenient term by which is designated a predisposition that 
may be either inherited or acquired. 

During the early infancy of children who have inherited the arthritic 
diathesis, there is a marked tendency to the occurrence of eczema and 
of impetigo. In this respect there is a strong resemblance between 
scrofulous and arthritic subjects, probably on account of the fact that 
in both there is an analogous disturbance of the nutritive processes. 
After the period of first dentition, catarrhal inflammations of the re- 
spiratory tract are exceedingly common. As the age of puberty is 



GOUT — ARTHRITIS URATICA. 659 

approached, articular rheumatism sometimes occurs. Epistaxis is fre- 
quent, and headache is often experienced. If gonorrhoea be contracted, 
it is exceedingly persistent and difficult of cure. Among gouty patients, 
simple catarrhal inflammations of the urethra, often accompanied by 
herpetic eruptions on the glans penis, are not uncommon. These in- 
flammations often complicate the mucous membrane of the bladder and 
epididymis. About the age of twenty-five years, a peculiar eczema is 
frequently observed, symmetrically occupying the sides of the thumb, 
index and middle fingers ; this appears periodically every spring, and 
disappears during the warm weather of summer. Dry and scaly forms 
of eczema are frequently developed in the folds of the joints ; and 
among the obese they assume the appearance of intertrigo. About the 
end of the third decade of life, dyspepsia begins to torment the patient. 
There is flatulence, eructation, pyrosis, and constipation. The urine 
becomes highly charged with urates and uric acid. About this time 
pruritus and haemorrhoids invade the rectum and the anal region. The 
least exposure to chill now excites obstinate inflammations of the re- 
spiratory passages. Granular pharyngitis and suppurative tonsillitis are 
frequently observed, and the inflammatory process may extend through 
the Eustachian tube into the middle ear, producing chronic otitis with 
all its disagreeable consequences. Congestive headache and hemicrania 
frequently alternate with each other. Boils often occur. The hair 
grows thin and falls from the scalp, and after a time the florid com- 
plexion gradually assumes an earthy discoloration as the liver becomes 
invaded by chronic functional disorders. Vertiginous attacks begin to 
develop, and gradually become more severe. Asthma, nephritic colic, 
and paroxysms of gastralgia now succeed one another as precursors of 
fully developed gout. The brain suffers with the other organs of the 
body. Irritability, impatience, loss of memory, reduction of the power 
of consecutive thought, and cerebral exhaustion, add to the anxieties of 
the patient. These vague and varied maladies often render life miser- 
able for a considerable period of time before the final outbreak of the 
gouty paroxysm. This usually occurs during the latter part of winter, 
when all the unfavorable influences that render life difficult in a severe 
northern climate concur to exhaust the individual. The patient retires 
to bed, weary, chilly, and feverish. After a few hours of unquiet sleep, 
about two or three o'clock in the morning, he is awakened by agonizing 
pain in the metatarso-phalangeal articulation of the great toe; the joint 
appears swelled, red, shining, and hot. At the end of several hours of 
exquisite suffering, the pain subsides, and as morning approaches, sleep 
becomes again possible ; a day of comparative comfort, is, however, 
succeeded by another night of agony, since the pain now returns at an 
early hour in the evening, and continues until the following morning. 

The pulse seldom rises above 100° F. Fever is continuous for about 
five days, and then gradually subsides. During the first two or three 
days there is severe frontal headache ; sometimes the patient is delirious 
at night ; during the day he is irritable and nervous ; the tongue is 
thickly coated, and sometimes dry in its central portion and at the tip ; 
there is thirst, loss of appetite, constipation ; scanty, high-colored, and 
scalding urine that throws down a copious sediment of uric acid and 



660 DISEASES OF NUTRITION. 

urates ; during violent attacks a little albumin may appear in the urine, 
but it disappears as the fever subsides ; the skin is dry at first, but 
about the fourth night it becomes moistened by a gentle perspiration 
that differs from the profuse, sour-smelling perspiration of acute articular 
rheumatism. 

During the first attack of gout the local manifestations are usually 
confined to a single one of the great toes, but during subsequent attacks 
both feet may be involved, and swelling appears in the joints of the 
tarsus, at the ankle, and in the knee. The joints of the upper ex- 
tremities and of the spinal column are rarely involved. Pain generally 
subsides after the third day ; the swelling diminishes ; redness dis- 
appears ; the skin becomes wrinkled, and desquamation occurs. Sup- 
puration never takes place, but in chronic cases the joints become 
permanently enlarged by the persistence of oedema, and by the deposit 
of urate of sodium. 

During the height of the febrile movement fine crepitant rales are 
sometimes heard at the base of the lungs. 

The gouty paroxysm is efficient in the dislodgment and discharge 
from the tissues of an immense amount of uric acid ; it is eliminated 
with the urine, and is present in the serum that exudes from blistered 
surfaces at a distance from the joints that are the seat of inflammation. 
If a blister be applied over such a joint, its serosity contains no uric 
acid. The increased oxidation that accompanies the fever serves to 
destroy and to expel uric acid and urates from the system. For this 
reason an acute attack of gout is usually followed by great improvement 
in the health of the patient, who often experiences for a time complete 
relief from the vague and sometimes obscure symptoms by which he 
had been previously tormented. An interesting example of this is 
related of the famous Lord Chatham (Lecky's History of England in 
the Eighteenth Century, vol. iii. pp. 133-156). 

In old and ill-treated cases of gout, the paroxysms tend to recur 
more frequently ; and finally the disease degenerates into chronic gout, 
in which there is no fever, and the joints remain permanently enlarged 
and cedematous. There is dull and continuous pain, which is never 
severe. Acute symptoms are entirely absent. Urate of sodium is 
abundantly deposited in the articular cartilages, and is accumulated in 
the circumjacent connective tissue, forming chalky concretions, known 
by the name of tophi. The joints gradually undergo disorganization, 
and the muscles, especially the extensors, become atrophied. 

The imperfectly developed paroxysms of chronic gout do not afford 
the relief that is experienced after an attack of acute gout. During 
the intervals the subordinate symptoms of the arthritic diathesis, such 
as tonsillitis, inflammations of the respiratory tract, haemorrhoids, 
urticaria, etc., are frequently renewed ; and sometimes their occurrence 
is followed by temporary relief from the sufferings that are caused by 
latent gout. The abrupt suppression of such acute manifestations is 
often followed by great general disturbance, or even by sudden death. 

Chronic gout exposes the patient to disease of the circulatory appa- 
ratus and of the kidney. The arterial structures are liable to inflam- 
mation, producing obstruction of the circulation, angina pectoris, and 



GOUT — ARTHRITIS URATICA. 661 

dry gangrene. The heart is exposed to fatty degeneration, with stag- 
nation of the blood as a consequence. Renal disease frequently accom- 
panies the changes in the arterial system, and is followed by hyper- 
trophy and dilatation of the heart, pulmonary oedema, bronchitis, and 
uraemia. In many cases rheumatism and gout are united in the same 
subject. 

Uric acid exists in excess in the blood in both chronic and acute 
forms of the disease ; it is especially abundant during the paroxysm ; 
it may also be recovered from the lymph and serous fluids of the body, 
and it is also present in many of the tissues ; from the blood or serum 
of a blister it may be readily obtained by the method of Garrod ; if a 
drachm of the serum be placed in a watch-crystal and acidified by the 
addition of six drops of ordinary acetic acid, crystals of uric acid will 
be deposited upon filaments teased out of a piece of thread, and dipped 
in the liquid for twenty-four hours ; the crystals thus deposited may be 
readily recognized by the aid of the microscope. 

The fibrin of the blood is not diminished in acute cases. Sometimes 
traces of oxalic acid are present as a consequence of decomposition of 
uric acid. 

Though an excess of uric acid is usually present in the blood, this 
is not uniformly the fact, and sometimes it may be redundant without 
any manifestations of gout; in the majority of such cases, however, 
other symptoms of the arthritic diathesis may be recognized. 

It was formerly thought that free uric acid or its salts were always 
present in excess in the urine of a gouty patient ; this, however, has 
been shown to be an erroneous opinion. Garrod was led by his obser- 
vations to entertain the belief that uric acid is diminished in the urine 
but increased in the blood in all forms of gout. Later investigations, 
however, have shown that the urine contains uric acid or its salts in 
quantity equal to or greater than the normal amount, except in certain 
chronic cases with interstitial nephritis, where the kidney is incapable of 
eliminating the waste of the tissues. 

The amount of urea in the urine is controlled by the appetite of the 
patient, and by the quality of his food. The phosphates are increased 
or diminished in a manner that corresponds with the changes that 
characterize the elimination of uric acid. 

In all forms of gout, and in the majority of arthritic subjects, the 
urine exhibits a constant excess of acid. An excessive amount of 
urate of sodium is held in solution by the acid phosphate of sodium. 
The blood contains an inordinate amount of acid that favors the deposit 
of urates. These accumulate about the joints, and by their chronic 
irritation of the circulatory apparatus and connective tissues of the 
different organs occasion the development of sclerosis, and other morbid 
changes in the heart, liver, kidneys, and elsewhere. 

An intimate connection between lead poisoning and the occurrence 
of gout has been noted by many observers. It is true that lead poison- 
ing and gout may both depend upon the indulgence of the same habits ; 
witness the fate of chronic beer- drinkers who have been poisoned with 
lead from the pipes through which beer was drawn for the gratification 
of an inordinate appetite for alcoholic beverages. It has, moreover, 



662 DISEASES OF NUTRITION. 

been ascertained that the presence of lead retards the elimination of 
uric acid ; it also hinders the molecular changes that depend upon 
oxidation within the tissues. Lead poisoning thus favors the accumula- 
tion of uric acid in the system. 

Saturnine, gout generally occurs in anaemic and cachectic patients. It 
rapidly invades many of the joints, and tends to degenerate into the 
subacute and chronic form of the disease : and. though the extremities 
exhibit a characteristic degree of (Edematous swelling, tophi rarely form 
about the joints or in the structures of the external ear. The kidneys 
and other internal organs, on the contrary, undergo rapid degeneration . 
Dropsy and uraemia are rapidly developed. 

Pathological Anatomy. The deformities that mark the dis- 
organization of the small joints, in cases of aggravated gout, are well 
known, and cannot escape recognition. But in minor forms of the 
I s w« the diarthrodial cartilages exhibit streaks of a dull-white color 
beneath the articular surface, where urate of sodium is deposited in the 
substance of the cartilage. These deposits gradually coalesce, and 
finally reach the surface, where they destroy the smoothness of the 
superficial cartilaginous layer. The process of erosion progresses, and 
the capsule of the joint becomes infiltrated with urate of sodium until 
the entire articulation is destroyed and buried in the centre of a chalky 
concretion. This process is most commonly experienced in the small 
joints of the hands and feet, especially in those articulations that have 
been the seat of frequent gouty inflammation. The larger joints of thebody 
usually escape, or are only invaded at a late period in the course of the 
disease. The process of infiltration commences at the centre of the 
articular cartilage, and is most conspicuous wherever the circulation of 
the blood is least abundant, or more easily retarded. For this reason the 
ligaments and other points of attachment are invaded at an early period. 
It is less common to find the synovial membranes infiltrated : and in 
their substance, also, the deposit commences where the circulation is 
least abundant. The synovial fluid does not exhibit any marked change, 
except in very chronic cases, when it appears turbid, and shows an 
acid reaction. 

The period of infiltration is not marked by inflammatory symptoms. 
but after the deposit of urates has reached an amount sufficient to 
irritate the tissues, secondary inflammation may be set up. which adds 
greatly to the enlargement and deformity of the diseased joint. In 
this way the articular surface undergoes ulceration, and the joint cavity 
becomes filled with a chalky mass of semi-fluid consistency, in which 
are sometimes found blood corpuscles and pus cells. These changes 
are especially common in the larger joints. The smaller joints 
frequently become anchylosed and immovable. 

Microscopical examination of the tissues in a gouty joint indicates 
that the infiltration of urate of sodium commences in the chondro- 
plastic cells of the cartilage, and that the intercellular substance is in- 
vaded at a later period. Certain observers are of the opinion that 
infiltration occurs indiscriminately wherever the vitality of the carti- 
lage has been sufficiently reduced by the excessive presence of urate of 
am in the nutritious fluids of the part. All. however, are agreed 



GOUT — ARTHRITIS URATICA. 663 

that the inflammatory processes by which the cartilages are softened 
and destroyed are of a secondary character, dependent upon previous 
infiltration of the tissue. The same successive changes may be noted in 
the non-cartilaginous structures of the articular capsule and ligaments. 

Outside of the joints the deposit of urate of sodium takes place at 
certain points, where the accumulated masses constitute the concretions 
designated by the name tophus. These tophi are formed in the neigh- 
borhood of the small joints of the hands and feet, in the sheaths of the 
flexors of the fingers, of the tendon of Achilles, in the lateral peroneal 
muscles, in the bursas of the great toe, metacarpal bones, olecranon, 
patella, and os calcis. Inflammation of these bursse may lead to sup- 
puration, with the formation of fistulous openings that communicate 
with the neighboring joints. Subcutaneous deposits of urate of 
sodium may exist at different points upon the surface of the body. The 
favorite seat of such deposit is in the auricle of the external ear, where 
rounded nodules of the size of a mustard-seed, or larger, may be dis- 
covered along the border of the helix, or between the helix and anti- 
helix, or upon the inner surface of the auricle. Similar concretions 
often exist in the eyelids, and in the alse nasi, along the ulnar surface 
of the forearm, upon the palmar surface of the fingers, and upon the 
internal aspect of the tibia. The superjacent skin sometimes becomes 
ulcerated and cicatrized. 

The kidney is, of all the internal organs, the one most liable to disor- 
ganization from gout. The gouty kidney is contracted ; its capsule is 
thickened and cannot be stripped off without tearing away portions of 
the subjacent tissue; the connective tissue is thick and retracted, giv- 
ing to the surface of the organ a roughened appearance ; numerous 
small cysts are also visible in its substance. The cortical portion is 
reduced in thickness ; the zone that contains the tubules is somewhat 
atrophied, and the pyramidal vessels are considerably congested. 
Microscopical examination reveals typical interstitial inflammation of 
the kidney. The parenchymatous structures of the kidney are conse- 
quently subjected to pressure and considerable atrophy, though the 
epithelium of the uriniferous tubules in the pyramidal portion is usually 
normal. In the cortical portion of the organ numerous cysts are 
formed by the obstruction and dilatation of the uriniferous tubules. 
These cavities contain a mixture of urine and urate of sodium. Some- 
times, however, the kidneys, in well-marked cases of gout, with infil- 
tration of the joints and advanced interstitial nephritis, are, neverthe- 
less, entirely free from any deposit of uric acid or urate of sodium. 
Amyloid degeneration of the parenchyma is occasionally observed. 

The heart is frequently hypertrophied, as a consequence of the same 
causes that produce changes in the kidney. Sometimes dilatation of 
the cavities of the heart, and fatty degeneration of its muscular fibres, 
occur. Occasionally deposits of urate of sodium are found upon the 
valves, but they are of rare occurrence, and must not be confounded 
with atheromatous deposits which occur in connection with general 
arterio-sclerosis. Atheromatous degeneration is almost universal 
among gouty subjects, and it is the cause of many of the visceral 
lesions that are developed in advanced cases of the disease. The fre- 



664 DISEASES OF NUTRITION. 

quent occurrence of cerebral hemorrhage or softening, and the incidence 
of angina pectoris, as a consequence of obstruction of the coronary 
arteries, illustrate the serious consequences that follow this form of 
degeneration in the organs of circulation. The same predisposition on 
the part of arthritic patients is illustrated by the frequent occurrence 
of varicose veins, hemorrhoidal tumefactions, -edema, purpura, etc. 

In the \ '". .■ tract concretions of urate : ac liam are some- 
times found in the cartilages and ligaments of the larynx, and in the 
similar structures of the bronchial tubes. To the irritation caused by 
the presence of urates in the concretions of the respiratory mucous 
membrane may be ascribed the frequent occurrence of catarrhal inflam- 
mation, pulmonary congestion, asthma, emphysema, and other respira- 
tory disorders. 

In the alimentary canal and its appendages, dilatation of the 
stomach and catarrhal inflammation are of frequent occurrence. It is 
seldom that any specific lesions can be discovered in the gastrointesti- 
nal canal other than those that may be occasioned by over-eating, by 
the abuse of medicinal remedies, or by uraemia. The liver is fre- 
quently in a condition of temporary hyperemia, but its permanent 
i ganization only occurs after the development of renal and cardiac- 
disease. Tatty liver is a common accompaniment of the obesity that 
sometimes accompanies gout. The intemperate habits and consequent 
gastro-intestinal lesions that are frequently observed among gouty 
patients afford sufficient explanation of the tendency to cirri. 
though many pathologists are of the opinion that gout . i:e a 

notable predis] siti d to that form of hepatic disease. 

In the nervous system such Lesions as exist are usually of a secondary 
character, presenting nothing of a specific nature. Occasionally dc 
its of orat I - lium or of uric acid have been found in the membranes 
of the brain and spinal cord, and in the neurilemma of the peripheral 
nerves. It is easy to imagine the possibility of consecutive inflamma- 
tion secondary to such concretions. 

Diagnosis. Acute gout is easily recognized, and the chronic form 
of the disease cannot be mistaken when the joints have become en- 
larged and disorganized. The occurrence of deposits in the cartilages 
of the ears, nose, larynx, and elsewhere, greatly aid the diagnosis. In 
doubtful cases the discovery of uric acid in the serous fluid of a blister 
is sufficient to establish the diagnosis of gout. In the absence of exter- 
nal manifestations of the disease, the recognition of visceral gout is 
often attended with considerable difficulty, unless the above method be 
employed. 

PROGNOSIS. The prognosis in gout is always a Berious matter, since 
it is very doubtful whether the diathesis can ever be transformed : 
though it is possible by the exercise of sufficient care to avoid frequent 
recurrence of the acute manifestations of the disc ise. Chroni 
is hardly ever curable, and when the heart, kidneys, or other important 
organs have undergone degeneration, sadden death is not an uncommon 
occurrei. 

TREATMENT. In cases that are marked by the existence of the 
arthritic diatb sis, eni assumes the greatest impor- 



GOUT — ARTHRITIS URATICA. 665 

tance. A mixed diet is desirable, but it must be enjoyed in moderation. 
Milk forms one of the most useful articles of food. Wine, cider, and 
beer should never be taken by those individuals in whom a gouty pre- 
disposition is manifest. Of these beverages, strong ale and porter are 
probably the most injurious. White wine and claret are less danger- 
ous than Burgundy and other wines that are rich in tannin and sugar. 
Abundant exercise in the open air should be encouraged, but all ex- 
cessive fatigue, both intellectual and physical, is to be avoided, since 
the paroxysm of gout is frequently provoked by exhausting efforts of 
any kind. A dry climate should always be preferred to damp and 
cold. Warm clothing, with flannel next to the skin, is desirable during 
the inclement seasons of the year. Every effort should be directed to 
the improvement of the cutaneous circulation by the use of sponge 
baths, flesh brushing, and massage. Even if it be impossible thus to 
avert the incidence of gouty phenomena, their severity may be greatly 
diminished. 

It is important to recognize the fact that every acute attack of ar- 
ticular gout is in a certain sense beneficial to the patient. Violent 
methods for its arrest or abridgment should be discouraged, in order to 
obviate the dangers that accompany the occurrence of retroeedent gout. 
With this purpose in view, the patient should be kept upon a low diet, 
but may be allowed to drink plentifully of cold water, lemonade, or any 
other agreeable beverage. Lithia water, Vichy water, and the solu- 
tions of granulated salts of potassium may be allowed ad libitum. The 
inflamed joints should be placed at rest in an immovable position, and 
anodyne lotions containing laudanum may be applied under an envelope 
of cotton surrounded by oiled silk or thin rubber cloth. It is unneces- 
sary to administer saline cathartics until the subsidence of the fever. 
Pain can be greatly relieved by the use of chloral hydrate, if the heart 
has not been weakened by previous attacks. Opiates must not be em- 
ployed. If the kidneys are not diseased, salicylate of sodium may be 
given in doses of ten grains every hour or two, but it must not be 
continued for any length of time. As soon as the paroxysm of pain 
and swelling subsides, the remedy should be discontinued. Great ele- 
vation of temperature may be reduced by the administration of fifteen 
grains of quinine. Vomiting, hiccough, and other gastric disturb- 
ances can be relieved by sucking ice, and by the application of mustard 
followed by a hot poultice over the epigastrium. When thoracic com- 
plications exist, cups or leeches should be applied to the walls of the 
chest. 

Colchicum is an ancient and highly esteemed remedy that enters into 
the composition of the majority -of anti-arthritic specifics. By its pre- 
mature employment there is a great risk of gastro-intestinal irritation, 
and the aborted paroxysm is liable to recur after a short interval of 
time. The best results are obtained by deferring the exhibition of the 
drug until the twelfth day of the attack ; at that time it may be given 
in doses of twenty drops of the tincture, two or three times a day. The 
remedy should be used with great caution, and should be suspended as 
soon as copious perspiration, diuresis, or diarrhoea occur. 

After the conclusion of the gouty attack great benefit is derived from 



DI5ZASZ5 OF NUTRITION. 

the con tinned use : salicylate if sc limn : it may be given for several 

the amount rf" sixty r eighty grains a day. I: augments the 

rge of nric acid, andhindr:- :: of urate of sodium about 

the joints. Oai be of potassium, and the bicarbonate of sodium 

produce similar good results The sodium salt maybe given to the 

amount of an ounce ~vith only beneficial effeo. except in 

^ itony and anaemia. Benzoic acid, the bemsc item, and 

the salts of lithium, ire ilso highly esteemed in the treatment of the 

lisease. Z h y are chiefly useful during the intervals between the 

h \11 cases the function of digestion should be carefully supervise 
Nux vomica, and other bitters, improve the appetite and aid the peri- 
staltic movements of the gastro-intestinal tube. Rhubarb, sulphur, 
cream of tartar, and the mineral wa^:- ire the favorite laxatives. 
ithol and bismuth are valuable intestinal antiseptics. When the 
liver is hypenemic. blue pill, or calomel in small doses, should be 
given daily for two or threr ireeks PiL hydrarg. mass., gr. j omn. 
n k : E . 

The natural mineral wa: era ire useful in the treatment of gout. 
Springs that contain bicarbonate of sodium are useful in sthenic cases, 
while the sulphate of sodium waters i re beneficial in cas e c : : _• i a : ro-intesti- 
Tarrh. When the isease : rincipally in volves the internal viscera the 
milder mineral waters containing solutions of bicarbonate of 

sodium and the sulphate or bicarbonate of calcium are to be preferred. 
Cbrorr. ifieetiona of the joints are benefited by friction, massage, and 
electricity. When the function of "digestion is not enfeebled, iodide of 
potassium is useful in doses of five to ten grains a day. 

In cases of rctroccdemi ~. the fcre :ment niu-~ e .ified ac 

_ bo the character : the - mptoms and the condition of the organ 
that is invaded. The attempt should be made to recall the 
the seat :•: its external manifestation by the application of mustard, or 
by blisters in the neighborhood of the affected joints. 



CHAPTER VII. 

KODULAB RHEUMATISM— ARTHRITIS DEFORMANS. 

Syi s NbdmUar rheum is a chronic, pi greas 

chart -:ence of pain and the development of de- 

formity in the mmencing in the smaller articulations, and 

progi nvading the larger, its course somewhat resembles that of 

The absence of uric acid and of the ui tea, g stoti least 
physiognomy approaching that of chronic rheumatism, hence the terms 
t and rht I arthritu that have been applied to this 

form of joint liseas — . especially among old people, 

the dis - limited to the hip-joint, hence the term morbus 



NODULAR RHEUMATISM — ARTHRITIS DEFORMANS. 667 

senilis. But usually it is in the joints of the fingers and of the toes 
that it commences, advancing thence into the larger joints of the ex- 
tremities of the body. 

The development of the disease is accompanied by pain of a vague 
and general character, sometimes assuming the form of neuralgia or of 
numbness and formication, accompanied by a feeling of stiffness in the 
limbs. These uncomfortable sensations are frequently worse at night, 
and are often the cause of persistent insomnia. Gradually these pain- 
ful sensations become concentrated about the articulations of the hands 
or feet; the joints are slightly swelled, painful on pressure, and some- 
what warmer than in health. Sometimes there is a slight discoloration 
of the skin. 

An attack of this sort soon subsides, but is liable to frequent relapses. 
After each paroxysm permanent traces of disorder remain, and at last 
the evidences of disorganization are unmistakable. As the disease de- 
velops, painful muscular spasms, usually involving the flexor muscles, 
are experienced. These spasms add considerably to the sufferings of 
the patient, and contribute largely to the deformation of the affected 
joints. 

Fig. 126. 




Types of deformity of the hand in rheumatoid arthritis. Type of flexion and its 
sub-varieties. (After Charcot.) 



Articular deformity is due to subluxation of the joints by muscular 
contracture, and also to chronic changes in the articular surfaces and 
peri-articular structures. The deformity of the fingers that is produced 
by muscular action is remarkably characteristic. When the action of 
the flexor muscles is predominant, the distal phalanges are flexed 
(Fig. 126), while the middle phalanges are forcibly extended, and the 



668 



DISEASES OF NUTRITION 



proximal phalanges are flexed upon the metacarpal bones ; the wrist is also 
in a state of flexion upon the forearm. In certain cases the third, 
fourth, and fifth fingers are laterally inclined towards the ulnar border 
of the hand. When the extensors are predominant, the distal and the 
proximal phalanges are inordinately extended, while the middle phalan- 
geal bones are flexed in the opposite direction. (Fig. 127.) 

Fig. 127. 




Types of deformity of the hand in rheumatoid arthritis. Type of extension and its 
sub-varieties. (.After Charcot.) 

Upon the feet, the great toe is bent outward over the other toes so 
that its articulation with the first metacarpal bone is inconveniently 
prominent. The foot itself may assume the position of valgus, or of 
varus equinus. The lower extremity of the femur is rotated outwards 
so that its internal condyle projects beyond the surface of the tibia, 
while the patella stands over the external condyle, and the leg is flexed 
upon the thigh. 

Sometimes the spinal column is also invaded, so that the mobility of 
its articulations is seriously impaired. The natural curvatures of the 
spine become exaggerated, producing considerable deformity. 

As the disease advances the extremities of the bones become enlarged 
by the growth of osteophytes which surround the borders of the articu- 
lar surfaces. This deformity is still further aggravated by the subluxa- 



NODULAR RHEUMATISM— ARTHRITIS DEFORMANS. 669 

tion of the joints, by the atrophy ot the neighboring muscles, and by the 
progressive thickening and induration of the peri-articular fibrous tis- 
sues. The skin in the neighborhood of the aifected joints becomes thin, 
pale, covered with perspiration, and sometimes closely adherent to the 
subjacent tissues. Sometimes the integument is thickened, cedematous, 
and livid. The nails become thickened, incurved, grooved, and brittle. 
Sometimes they become detached and fall off without any apparent 
cause. In like manner the hair falls out. The subcutaneous connective 
tissue is atrophied, and the aponeuroses, especially the palmar 
aponeurosis, become thickened and contracted (Dupuytren's fingers). 

It is worthy of note that when the disease develops in youthful sub- 
jects, the extremities are deformed and crippled by these different modes 
of contracture and subluxation, while among old people the principal 
cause of deformity lies in the development of osteophytes upon the ex- 
tremities of the bones. 

It is also important to note the fact that when the disease originates 
at an early period of life it is much more amenable to treatment than 
when its commencement is deferred until middle life or old age. 

Occasionally chronic diseases of the heart, pericardium, and aorta, 
are associated with nodular rheumatism. Sometimes the cutaneous, 
nervous, and renal disorders that accompany the arthritic diathesis may 
be found coincident with nodular rheumatism. Not unfrequently such 
patients become tubercular, and succumb to chronic pulmonary disease. 

The symmetrical character of the lesions, the systematic atrophy of 
the muscles, the progressive lesions of the bones, the fulgurant pains, 
the rapid palpitation of the heart, and the trophic changes in the skin 
that are observed in nodular rheumatism, so closely resemble the cor- 
responding lesions that accompany dorsal tabes, hemiplegia, paralysis 
agitans, exophthalmic goitre, and other nervous disorders, that many 
pathologists incline to the belief that their common cause must be 
sought in the nervous system. With regard to the nature of that 
cause, if it exists, it must be admitted that little or nothing is known. 

Pathological Anatomy. In all the varieties of senile arthritis and 
of nodular rheumatism the articular lesions are identical, though the 
extent of their evolution may vary. The characteristic changes consist 
in a villous condition of the articular cartilages, hypertrophy of the 
synovial fringes, and the growth of cartilaginous processes or osseous 
stalactites around the borders of the joints. Upon the articular surfaces 
the cartilage cells proliferate and become encapsulated. The superficial 
cells rupture and break down, while the subjacent capsules develop into 
villous processes, like the pile of velvet. 

In mild forms of the disease there is little or no effusion about the 
joint, and the existing deformity is chiefly the result of atrophy of the 
muscles and peri-articular tissues. Sometimes the fibrous tissues around 
the joint become thickened and retracted so as to produce stiffness or 
partial dislocation of the articulation. 

In severe and chronic forms of the disease, all the tissues that enter 
into the formation of the joint are involved. The synovial fringes be- 
come thickened, and finally are infiltrated with calcareous matter. The 
cells of the diarthrodial cartilages proliferate and undergo a villous 



670 DISEASES OF NUTRITION. 

transformation. In this softened condition the articular surfaces are 
worn away until the subjacent bone is laid bare. The ends of the bones 
also undergo a process of eburnation by which they are rendered more 
resistant, though less adapted to freedom of motion. While this erosion 
goes on at the centre of the articular surface, the proliferating activity 
of the marginal structures results in an exaggeration of cellular growth, 
which, at first, consists in enlargement and swelling of the marginal 
portion of the articular cartilages. After a time the new growth be- 
comes infiltrated with calcareous salts, and osteophytes are thus formed 
around the joint. Somewhat similar changes are manifested in the 
inter-articular ligaments and cartilages. In certain cases anyklosis is 
produced by the development of fibrous bands that bind the joint sur- 
faces firmly together. 

In many cases the bones become exceedingly friable through fatty 
degeneration of the marrow and absorption of the osseous framework of 
the bone. 

In the knee and elbow joints the synovial fringes undergo cartilagi- 
nous transformation, and may become infiltrated with calcareous salts. 
The projecting filaments sometimes become detached, and accumulate 
within the cavity of the joint, where they exist as foreign bodies re- 
sembling in appearance grains of boiled rice. 

The most characteristic feature of chronic nodular rheumatism is 
the deformity that is produced by the more or less complete destruction 
of the joints by the thickening and retraction of the adjacent fibrous 
tissues, by the development of ecchondroses and osteophytes, and by 
the dislocation that results from the irregular traction of the muscles 
that are connected with the articulations. Joints which, like the hip- 
joint, are not easily displaced by muscular action, present the least 
amount of luxation, and are the seat of the greatest degree of osseous 
growth. In addition to the changes that are thus directly produced, 
the deformities are aggravated aud rendered more conspicuous by the 
results of chronic neuritis, and by the trophic changes in the skin and 
subjacent tissues which complicate the disease. 

Etiology. Chronic nodular rheumatism occurs at all periods of 
life, but is most frequent between the ages of forty and sixty years. 
The disease is more common among women than among men, especially 
among the poor. It frequently accompanies dysmenorrhoea and rapidly 
successive 'pregnancies. When it thus attacks young women, it may be 
frequently cured, or may disappear spontaneously. It often develops 
at the time or menopause, and gradually increases in severity during 
the remainder of life. Hereditary influences are often conspicuous, 
but they are usually indicated by the existence of a general arthritic 
predisposition. Such patients are subject to frequent headaches, and 
chronic dyspepsia that is aggravated by the slightest departure from the 
ordinary habits of life. They are intolerant of alcohol, tobacco, tea, 
and coffee. If the liver and the kidneys or the skin become in any way 
hindered in the performance of their functions, a tendency to articular 
pain and disorder is at once manifested, as if the joints were in some 
way compelled to act the part of supplementary organs of elimination. 

Exposure to dampness and cold is a common cause of the disease, 



NODULAR RHEUMATISM — ARTHRITIS DEFORMANS. 671 

especially when such exposure is continuous by reason of the occupa- 
tion or residence of the individual. Especially unfavorable is the 
influence of cold when associated with privation and suffering. The 
disease is far more common among the indigent than among the upper 
classes. It is also often associated with scrofula, 'pulmonary consumji- 
tion and albuminuria ; and, like those maladies, appears to be the 
result of physical degradation. Its association with gout and with 
rheumatism is much less intimate. It also presents many points of 
resemblance to those arthropathies of nervous origin which are devel- 
oped in connection with certain nervous diseases like tabes dorsalis, 
hemiplegia, and paralysis agitans. 

Nodular rheumatism is frequently excited by the uterine disorders 
of females. Menstrual disorders, frequent pregnancy, and prolonged 
lactation, are often accompanied or followed by the development of the 
articular disease. 

Diagnosis. Arthritis deformans is distinguished from gout by 
the absence of paroxysmal attacks, and by the fact that the disease 
manifests no predilection for the great toe. Urate of sodium is not 
deposited about the joints, and there is no accumulation of that sort 
under the skin of the ear, elbow, or elsewhere. Chronic articular 
rheumatism exhibits a higher degree of local inflammation. Chronic 
tubercular joint diseases sometimes resemble some of the features of 
nodular rheumatism, but they do not produce the characteristic de- 
formity of the articulations. 

Treatment. A dry, warm climate is desirable for the subjects of 
nodular rheumatism. Flannel should be worn next to the skin by day 
and by night. When the power of digestion is sufficient, cod-liver oil 
is useful. Iron should also be prescribed for young and anaemic pa- 
tients. Local friction of the joints with stimulating liniments promotes 
the circulation. Pain may be relieved by full doses of antipyrine or 
salol ; salicylate of sodium is less successful. Chloral and phenacetine 
seldom afford much relief. Severe suffering can rarely be relieved 
without recourse to opiates. Small doses of the tincture of colchicum 
are sometimes beneficial. The remedy should be given for two weeks, 
then suspended for an equal length of time. In this way it may be 
administered until the disappearance of pain. Carbonate of sodium, 
and other alkaline salts, may be given in large doses for a long time 
with great benefit ; associated with quinine it may be given to the 
amount of an ounce a day. 

When the acute symptoms of the disease have been subdued, the 
most valuable remedies are iodine in combination with alkaline bases, 
and arsenic. The compound tincture of iodine may be given at meal- 
time, morning and evening. The dose should be gradually increased 
from five drops to half a drachm. 

When arsenic is given, it should be administered in the form of 
Fowler's solution after meals ; the dose may be increased from two to 
six drops ; this drug frequently causes aggravation of the symptoms of 
the disease when it is first administered, but after a time tolerance is 
established, and improvement follows, except in aged patients and in- 
veterate cases. The ammoniacal tincture of guaiac produces similar 



672 DISEASES OF NUTRITION. 

effects. Warm baths containing arseniate and bicarbonate of sodium, 
have been recommended ; it is, however, doubtful whether they pro- 
duce any beneficial result that cannot be ascribed to the warmth of the 
water itself. At first the baths should be taken every other day ; but 
the patient should remain warm in bed for an hour or two after each 
bath. If pain is aggravated by these baths, it may be relieved by the 
administration of a grain of the extract of conium, with Dover's pow- 
der at night,' and the joints may be rubbed with an anodyne liniment. 

R .— Tr. aconit. rad. \ _.. 

Tr. belladon. f aa dlJ> 

Tr. camphor. . . . . . . Sss. 

Chloroform. . . . . . . 5j, . 

Lin. sapon. ........ ^vj. — M. 

During such a course of treatment the patient should take from three 
to ten grains of iodide of potassium with the elixir of calisaya bark 
before each meal. After the subsidence of acute symptoms daily mas- 
sage and frequent movements of the affected joints will be found benefi- 
cial. These exercises may be advantageously employed during the 
bath. At first the movements are painful, but their cautious repetition 
is attended finally with excellent results. It is usually necessary to 
prolong this treatment for a month at least. Even in those obstinate 
cases that are incurable, a great amount of temporary relief is usually 
obtained. A repetition of the treatment is desirable during the course 
of every spring and autumn. In many cases the Turkish bath is very 
beneficial, and the domestic method of sweating the patient over an 
alcohol-lamp is not to be despised. Seaside resorts and sea bathing are 
to be avoided. Hot mineral waters that contain chlorides, sulphur, 
and arsenic, are greatly to be preferred. In moderate forms of the 
disease warm mud baths are sometimes useful. The local application 
of iodine, blisters, and the actual cautery, is sometimes followed 
by relief. Daily massage is exceedingly useful as a means of pre- 
venting muscular atrophy, and of promoting the nutrition of the 
affected tissues. The galvanic current has been employed with moder- 
ate success. Large sponge electrodes should be used, placing the posi- 
tive pole upon the spine, while the negative pole is applied to the 
affected part, either directly, or by communication with a warm bath 
in which the diseased extremities are placed. The current should be 
applied for ten or fifteen minutes every day, for a month ; after that 
time, at longer intervals. 

Of all the remedies above mentioned, the two most successful are 
iodine and warm baths. 



CHAPTEE VIII. 

ACUTE RHEUMATISM— POLYARTHRITIS ACUTA. 

Symptoms. Acute rheumatism usually commences quite abruptly, 
with a severe chill, or with repeated chilly sensations. Occasionally 
the disease begins with a feeling of general discomfort and transient 



ACUTE RHEUMATISM. 673 

pains in the joints for two or three days before the outbreak of the 
fever. The temperature rapidly rises to 103° or 104° F., and it is 
irregular in its course. The pulse and respiration become more fre- 
quent ; the tongue is coated ; appetite disappears ; there is great thirst ; 
the bowels are confined ; the urine is scanty, high colored, extremely 
acid, and sometimes contains a little albumin ; it frequently deposits a 
copious sediment of urates ; the shin is covered with a copious acid 
perspiration which often occasions miliary eruptions upon the surface ; 
the red blood-corpuscles rapidly diminish, while the white corpuscles 
are greatly increased in number. 

Simultaneously with the commencement of the fever, one or more of 
the joints in the lower extremities begin to swell and to become pain- 
ful ; usually the larger joints are principally affected, but not unfre- 
quently the articulations of the fingers and toes are invaded. It is 
frequently observed that inflammatory symptoms rapidly develop in a 
joint and as rapidly subside, only to reappear in some other joint. 
Sometimes nearly all of the joints of the body are invaded, either 
simultaneously or in rapid succession. 

The occurrence of inflammation causes swelling and redness of the 
skin over the affected joint. The tissues are oedematous and pit on 
pressure, since the swelling is caused chiefly by transudation into the 
subcutaneous areolar tissue rather than into the cavity of the articula- 
tion. Every form of movement is attended with intense suffering, so 
that the victim of acute polyarthritis becomes as helpless as if he were 
paralyzed. The limbs assume such positions as are attended with the 
least pain, and every attempt at movement is followed by great suffer- 
ing. Sometimes painful motion occasions an audible creaking, which 
is dependent upon inflammation of the fibrous capsule and tendinous 
sheath, rather than upon the actual changes within the articular 
cavity. 

Acute rheumatism may subside spontaneously in a few days, or it 
may continue from four to twelve weeks, or longer. Partial recovery 
is frequently followed by relapse. In such protracted cases febrile 
symptoms gradually subside, and all the phenomena tend to assume a 
moderate degree of intensity. Convalescence is very gradually estab- 
lished, and the patient remains pale and anaemic for a long period of 
time. 

Certain forms of masked rheumatism may exist, in which the 
disease involves, not the joints, but the nerves, especially the tri- 
geminal nerve, producing severe neuralgia, sometimes associated with 
endocardial inflammation. In certain cases the pericardium, or the 
endocardium alone, undergoes inflammation, without intercurrent joint 
disease or neuralgia. All these forms of rheumatism yield readily to 
the administration of salicylic acid. 

Endocarditis is a very frequent complication of articular rheuma- 
tism ; sometimes it assumes the ulcerative form. Pericarditis is a less 
common event. Occasionally myocarditis results from embolism of 
the cardiac arteries, or directly from the action of the original causes 
of the disease. 

Cerebral rheumatism sometimes occurs. This is usually accom- 

43 



674 DISEASES OF NUTRITION. 

panied by high fever, delirium, and stupor. It is a very fatal compli- 
cation, and death is often preceded by an extraordinary elevation of 
temperature, which sometimes reaches 110 c F. In certain cases the 
symptoms closely counterfeit those of meningitis. Genuine inflamma- 
tory exudation, however, is rarely discovered after death. Sometimes 
paralysis and other cerebral symptoms are induced by the occurrence 
of embolic obstruction in the cerebral arteries. When severe inflam- 
mation of the kidneys accompanies the evolution of rheumatism, uraemic 
intoxication sometimes occurs. 

Occasionally the articular inflammation results in suppuration and 
destruction of the joints. Sometimes the sheaths of the tendons become 
enlarged by the growth of painful excrescences that consist of connective 
tissue and fibro- cartilage. These growths, which are usually observed 
among children, gradually disappear : but sometimes they persist for a 
long time, and occasion contracture of the affected tendons. Ahst 
in the muscles are sometimes observed. Various eruptions upon the 
skin are not uncommon. Among these may be specified roseola, 
urticaria, erythema, herpes, erysipelas, purpura, and bullous vesicles or 
pustules. Sometimes little nodular tumors may be discovered under 
the skin over the forehead and occiput, and elsewhere. Occasionally 
the veins become obstructed by thrombi. Rheumatic inflammation of 
the iris and paralysis of the oculo-motor nerves have been observed. 
Catarrhal affections of the respiratory mucous membranes are not un- 
common. Sometimes pleurisu. pneumonia, and peritonitis may exist 
as complications of the disease. Acute inflammation of the kidneys, 
cystitis, and urethritis, have been already described. Hcematuria may 
exist as a consequence of renal embolism, or of the excessive use of 
salicylic acid, so that it is not always an indication of acute nephritis. 

It is evident from this review of the possible complications that many 
subsequent diseases and disorders may follow the occurrence of acute 
rheumatism. Sometimes ankylosis of the joints remains, and is fol- 
lowed by rapid muscular atrophy. The spinal cord may be invaded 
by the disease, producing paraplegia, and paralysis of the bladder. 
Other paralytic affections may result from cerebral lesion, or from 
peripheral neuritis. Valvular diseases of the heart are not uncom- 
mon sequela? of the disease. Chronic nephritis, chorea, and mental 
derangement must be enumerated among the permanent consequences 
that occasionally follow acute rheumatism. 

Pathological Anatomy. Since only about three per cent, of the 
cases of acute rheumatism prove final, comparatively little is known 
regarding the pathological changes that accompany the disease. 
Capillar >i hemorrhages have been observed in the mediastinum and 
under the serous membranes of the heart, pleural cavity, peritoneum, 
and meninges. Similar effusions occur in the spleen, heart, liver, and 
kidneys. The spleen is enlarged and soft. The eardia s ties are 

relaxed, and exhibit the appearances of cloudy swelling and granular 
degeneration. The joints usually contain but little fluid : sometimes, 
however, they are occupied by a turbid, flocculent, and sometimes puru- 
lent effusion. The synovial membranes and the articular cartilages 
are congested. The svnovial fringes are swollen, and the cartilages 



ACUTE RHEUMATISM. 675 

exhibit proliferation of the capsules and cartilage cells. Occasionally 
fibrinous adhesions exist between the ends of the bones, and sometimes 
there is some degree of erosion involving the articular cartilages. 

Etiology. Nothing certain has yet been ascertained regarding the 
ultimate cause of acute rheumatism. It is usually ascribed to the re- 
sults of exposure to cold and damp ; this, however, is only giving 
prominence to an exciting cause. Many facts may be urged in favor of 
a parasitic origin of the disease, though the presence of a specific micro- 
organism has never been demonstrated. Staphylococcus pyogenes 
aureus has been discovered in the exudations of rheumatism, but there 
is no satisfactory evidence to prove that this particular microorganism 
is the contagious agent. Still, the quasi-epidemic occurrence of rheu- 
matism, its connection with particular localities and houses, its evident 
relation w T ith cold and dampness which favor the occurrence of other 
infective diseases, the febrile character of its course, the enlargement of 
the spleen, and the tendency to capillary hemorrhages that is observed 
when opportunity is afforded for examination of the tissues after death, 
all indicate a most intimate relationship with other infective disease. 

The influence of cold, especially when acting upon the overheated 
and perspiring body, cannot be questioned. Sudden refrigeration under 
such circumstances is a most efficient exciting cause when the rheumatic 
predisposition has been already established. For the same reason ex- 
cessive physical and mental fatigue favors the onset of the disease. 
Injuries, especially those which involve the joints by twisting or strain- 
ing the articular ligaments frequently cause a determination of rheumatic 
inflammation to the injured locality. Heredity is frequently assigned 
as a cause of rheumatism. There is, however, no direct transmission of 
the disease. It is possible that a hereditary lack of resistance may be 
transmitted. The influence of sex and of occupation produces com- 
paratively little effect upon the distribution of the disease. Its articular 
forms are most frequently observed during the first fifteen years of 
adult life. In childhood, and in more advanced life, masked forms of 
the disease are more common. 

Previous experience of the disease operates as a predisposing cause 
for its return. The more frequently it recurs the more often it is liable 
to relapse, until it finally becomes merged into the form of chronic 
rheumatism. 

Diagnosis. Simple, acute rheumatism is easily recognized, but its 
complications may escape notice for a time, unless the precaution be 
observed to make frequent examination of the heart and other organs 
of the body. The articular disease must be differentiated from those 
acute inflammatory conditions of the joints which sometimes accompany 
or follow other infective diseases, such as pyaemia, puerperal fever, 
diphtheria, syphilis, gonorrhoea, etc. The acute attack of gout usually 
invades the joint of the great toe, and there is a greater degree of 
venous dilatation in the neighborhood of the affected articulations. Ex- 
foliation of the epidermis is more commonly observed in gout than in 
rheumatism. The fever of gout is less continuous than that of rheu- 
matism ; the amount of perspiration is less copious, and it does not 
possess the peculiar sour smell that characterizes the rheumatic sweat. 



676 DISEASES OF NUTRITION. 

Prognosis. The immediate prognosis is almost always favorable in 
acute rheumatism, since the mortality does not exceed three per cent. 
Complications involving the heart, the lungs, and the brain, add greatly 
to its dangers, and the after-effects that follow endocarditis, nephritis, 
and other internal complications, are often attended with great danger. 

Treatment. During the acute stage of rheumatism the diet should 
consist chiefly of liquids. Cold water and lemonade may be given 
freely. Good ventilation is needed, but an even temperature of 65° to 
70° F. is desirable. The patient should be clothed in a flannel night- 
dress, and should lie between blankets or flannel sheets. 

It was formerly the custom to administer alkaline salts in large 
doses, until the urine became neutral or slightly alkaline. Dover's 
powder was necessary to relieve the suffering of the patient ; but at present 
these remedies have been almost entirely superseded by salicylic acid 
and its salts. These remedies should be given in doses of ten grains 
every hour, until a distinct humming or buzzing is audible in the ears. 
The drug may be then suspended for two or three hours ; and then re- 
newed hourly until the same experience is repeated. Thorough satura- 
tion of the blood with the medicine is quickly followed, in the majority 
of instances, by relief from pain and subsidence of the swelling. The 
more acute the inflammatory symptoms, the greater the degree of 
relief. As the febrile and painful condition disappears the remedy may 
be given less frequently, once in three, four, five, or six hours, but it 
must not be wholly discontinued until a week or ten days have elapsed, 
otherwise a relapse may be anticipated. The occurrence of endocardial 
inflammation need not prevent the administration of salicylic acid, 
but more care should be exercised to avert any tendency to heart 
failure. 

When salicylic acid and its compounds cannot be longer tolerated 
by the stomach, salol is frequently efficient. This may be given in 
doses of ten or fifteen grains every two hours until the subsidence of 
fever and swelling. The dose may then be given at longer intervals. 
It is worthy of note that other febrifuge remedies, like antipyrine, in 
fifteen-grain doses every three or four hours, produce similar results, 
though by no means as reliable agents as salicylic acid. Occasionally, 
however, one of them will produce a better effect than the acid. 

If in spite of this active medication, painful swelling persists, much 
benefit is often obtained from hot fomentations, frequently renewed, 
upon the affected joint. Sometimes great relief is afforded by fixation 
of a large joint by the application of a plaster-of-Paris splint. Con- 
tinuous pressure, however, is liable to be followed by muscular atrophy, 
requiring the continued use of the faradic current for its cure. 

In certain cases of rheumatic arthritis which resist other forms of 
treatment, rapid relief is obtained from the administration of the tinc- 
ture of colchicum seeds, given in doses of ten drops three or four times 
a day. Associated with full doses of the tincture of aconite root, it 
sometimes is followed by most satisfactory results. It is probable that 
in these cases a gouty predisposition actually exists. 

Since the depression of temperature by any method is usually fol- 
lowed by relief in rheumatic inflammation, considerable benefit is often 



CHRONIC RHEUMATISM. 677 

obtained by other remedies that dimmish the liberation of heat within 
the body. For this reason relief is sometimes procured by the adminis- 
tration of fifteen-grain doses of quinine or salacine. 

Certain cases of rheumatism will, nevertheless, be found intractable 
by any of the measures above recommended. The application of can- 
tharides plasters to the affected joint is, under such circumstances, fre- 
quently followed by prompt and effectual relief. Lingering cases that 
have dragged along for many days or weeks, without benefit from other 
treatment, sometimes experience such release from pain as soon as the 
blister begins to draw that they eagerly call for its repetition whenever 
and wherever the articular inflammation manifests itself. 

During the subsidence of the disease, and in subacute cases that 
manifest a tendency to chronic duration, considerable improvement 
frequently follows the use of chloroform liniment, or the application of 
turpentine. Strong tincture of capsicum is also of considerable service 
as a local application. The resulting improvement is principally due to 
the quickened circulation of blood in the affected parts. 

During the later stages of a protracted case of rheumatism, when 
the blood has become impoverished, iodides and iron are useful. The 
syrup of the iodide of iron, in half- drachm doses every four hours, 
often affords great benefit. 

The occurrence of cerebral symptoms and an unusual elevation of 
the temperature require the active employment of phenacetine, acetan- 
ilide, or antipyrine, in full doses. Moderately warm baths, in which 
the patient should lie for an hour at a time, may be employed with 
considerable hope of advantage. 

Chronic Rheumatism — Polyarthritis Chronica. 

Etiology. Chronic rheumatism is generally experienced after the 
middle period of life. It is sometimes the result of an acute attack 
which partially subsides and degenerates into a subacute, persistent, 
and sometimes permanent articular inflammation. In many cases, 
however, it originates as a subacute and chronic inflammation without 
any very acute or conspicuously inflammatory symptoms. It is fre- 
quently excited by exposure to cold, and by a residence in damp and 
unwholesome apartments. 

Symptoms. The disease runs its course without fever, though some- 
times exacerbations may occur, which are accompanied by a febrile 
movement that, for the time being, suggests a moderate paroxysm of 
acute rheumatism. The heart and other internal viscera, however, 
very rarely manifest any tendency to participation in the disease. The 
larger joints of the extremities are the favorite localities for its mani- 
festation. Sometimes the smaller joints of the hand and foot are also 
invaded. Occasionally a moderate degree of swelling and slight red- 
ness of the skin about the affected joint may be observed, but in the 
majority of cases these symptoms are absent, and the disease is indi- 
cated by the occurrence of pain in the articulations. This may be felt 
more or less continuously, or it may be experienced only on pressure 
over the joint, or during the act of moving the limb. After a time 



678 DISEASES OF NUTRITION. 

there is thickening of the articular capsule and other adjacent fibrous 
tissues, so that a certain amount of creaking may be heard when the 
joint is flexed and extended. In old cases, more or less complete an- 
chylosis may be developed, accompanied by chronic enlargement and 
deformity of the affected joints, which, however, do not exhibit the 
characteristic subluxation and deformity that characterize arthritis 
deformans. Rapid muscular atrophy, involving the muscles on the 
proximal side of the joint, is not unfrequently observed. 

The duration of chronic rheumatism is exceedingly tedious. It fre- 
quently becomes a life-long disease, crippling the patient and render- 
ing him uncommonly sensitive to changes of the weather. These pre- 
monitions of approaching atmospheric disturbance appear to be con- 
nected with the variations of barometric pressure that precede the 
coming of an extended rainfall or other cyclonic commotion. 

Pathological Anatomy. The principal pathological changes in 
chronic rheumatism involve the articular capsule, its synovial lining, 
the synovial fringes, and the diarthrodial cartilages. The synovial 
fluid is very scanty in amount ; the synovial fringes become thickened ; 
the cartilage cells proliferate and then undergo degeneration and absorp- 
tion, thus producing erosion of the joint surfaces. Sometimes fibrous 
bands are thrown across the space between the ends of the bones, 
causing anchylosis, and more or less obliteration of the articular 
cavity. 

Diagnosis. Chronic rheumatism may be readily distinguished from 
gout by its gradual development, by the absence of uric acid from the 
blood, and by the fact that mineral concretions never form around the 
joints or beneath the skin. The earlier paroxysms of gout usually 
attack the great toe joint, for which chronic rheumatism seldom mani- 
fests any partiality. It is more difficult to distinguish between old cases 
of chronic rheumatism and arthritis deformans, but the rheumatic dis- 
ease is frequently preceded by one or more attacks of acute rheumatism, 
and the articular deformity exhibits a more decidedly inflammatory 
origin, course, and history, than is observed in arthritis deformans. 

Prognosis. So far as a fatal termination is concerned, the prog- 
nosis is exceedingly favorable ; but the duration of the disease cannot 
be foreseen; and the degree of incapacity for the enjoyment of life 
and its active occupations is beyond any possibility of estimation. 

Treatment. The remedies that are useful in the treatment of acute 
rheumatism will be found of service in the chronic disease ; but their 
effects are less rapidly manifested, and are much more uncertain in their 
development. Iodide of potassium, colchicum, and aconite should be 
administered after the exhibition of salicylic acid and its congeners. 
The local use of liniments and strong tincture of iodine sometimes 
affords relief. Powdered gum guaiac, in doses of five grains every four 
hours, and the ammoniated tincture of guaiac (one drachm, in milk, 
three or four times a day), sometimes operate beneficially. Hot brine 
baths repeated every day for a month or six weeks, often prove very 
effectual, especially when associated with active manipulation of the 
muscles by massage, together with judicious movement of the affected 
joints while in the bath. Turkish baths, sulphur baths, and hot mud 



MUSCULAR RHEUMATISM. 679 

baths, are sometimes followed by good results. The internal adminis- 
tration of sulphur mineral water, or small doses of lac sulphur are 
found beneficial. 

R . — Lac sulphur gr. v. 

Potass, bitartrat. gr. j. 

Sacch. lact gr. x. — M. 

The old-fashioned " Chelsea Pensioner" owed its reputation in the 
treatment of chronic rheumatism among the worn-out pensioners of the 
British navy to the sulphur, cream of tartar, and guaiac that it con- 
tained. 

Active counter-irritation with the faradic current and the electric 
brush sometimes affords relief, but it is a remedy of less efficacy than 
massage associated with the use of stimulating liniments and other 
irritant applications, unless the muscles have undergone atrophy. 

Muscular Rheumatism — Rheumatismus Musculorum. 

Etiology. Muscular rheumatism is not uncommon among children 
and young people, but it is more frequently observed after the middle 
period of adult life. It is often experienced by successive generations 
in the same family line. Its most common exciting cause is exposure 
to wet and cold, especially during perspiration. Unilateral refrigeration 
by sitting before an open window, or standing in a strong draught of 
cool damp air, is a very common means of exciting the disease. 

Pathological Anatomy. Since muscular rheumatism never proves 
fatal, nothing is known regarding the pathological changes that accom- 
pany its course. Its affinity with other forms of rheumatism suggests 
the possibility of an infective cause, either from without, or originating 
by a process of auto-infection. The seat of the disease is in the fibrous 
connective tissues of the muscles. In severe cases it is probably accom- 
panied by transient inflammatory processes which, however, are ex- 
ceedingly evanescent and migratory. 

Symptoms. The cardinal symptom of muscular rheumatism is a 
painful condition of the affected muscle. This may be either constant, 
paroxysmal, or evoked by local pressure. The local manifestation is 
subject to great variability, and frequently shifts its seat from one mus- 
cular mass to another, without any apparent cause. This migratory 
character is chiefly displayed by the minor forms of the disorder. 
Severe attacks of the disease frequently exhibit a degree of local per- 
sistence rivalling that of chronic articular rheumatism. In such cases 
slight fever is frequently present, and there may be a moderate eleva- 
tion of the temperature- In the majority of cases the disease is 
unaccompanied by any febrile movement, and the patient continues in- 
his daily avocation, though frequently subjected to considerable incon- 
venience and suffering in the use of the affected muscles. No part of 
the muscular apparatus of the body is exempt from the disease. It is 
often a source of considerable pain connected with the movements of 
the eyeballs, or other movable portions of the head, face, throat, and 
neck which are particularly exposed to the influence of cold. When 



680 DISEASES OF NUTRITION. 

the muscles of the fauces are invaded there is considerable pain accom- 
panying the act of deglutition. The patient compains of sore-throat, 
though no visible appearances of inflammation be afforded by inspection 
of the fauces and pharynx. Possibly in the course of a few hours these 
symptoms may entirely disappear, to be succeeded by corresponding 
difficulties in the cervical muscles or in the muscles of the shoulder 
and thorax. Painful and difficult respiration may be thus produced 
in certain cases. The abdominal muscles, especially the recti muscles, 
are often thus affected ; and a favorite locality for the manifestation of 
the disease is presented by the muscles that support the spinal column. 
In severe forms, involving the cervical region, the head may be twisted 
and drawn to one side (rheumatic torticollis). In many cases the 
laryngeal muscles and the bronchial mucous membrane are the seat of 
the disease, producing a harassing cough that may persist for many 
months. Complete and sudden relief from this symptom is afforded by 
the migration of rheumatic symptoms to the external musculature of 
the body and extremities. Irritation of the cardiac muscles may be 
in like manner produced, occasioning irregular and unusual movements 
of that organ. The oesophageal, gastric, and intestinal muscular layers 
are also sometimes invaded, producing temporary painful conditions 
that are characterized by uneasiness, or even by pain of considerable 
severity, during the peristaltic contractions of the alimentary canal. In 
like manner the muscles of the perineum, rectum, and urethra may 
become temporarily painful, when subjected to unusual and violent 
contraction during the acts of defecation, micturition, and copulation. 

Like other forms of rheumatism, the muscular disease may be either 
acute or chronic. Acute attacks are often very brief, and may be 
readily relieved, but the chronic form may persist for weeks and 
months together. With advancing age the disease becomes more invet- 
erate, so that many elderly people suffer exceedingly during the colder 
montns of the year from this cause. Sometimes the connective tissue 
of the affected muscles becomes permanently thickened and contracted, 
producing a certain amount of local deformity. Sometimes endocarditis 
and myocarditis become associated with muscular rheumatism. 

Diagnosis. The disease may be readily recognized by the history 
of the patient, who soon learns to understand the nature of his symp- 
toms, and to refer them to their appropriate cause. A condition of the 
muscles in which they are painful without previous injury can scarcely 
be ascribed to anything else. When the muscles of the abdominal wall 
are invaded, the disease may be distinguished from peritonitis by the 
absence of fever, and by the fact that they are painful when compressed 
between the fingers in a manner that prevents the incidence of pres- 
sure upon the peritoneum or subjacent viscera. 

• Treatment. The treatment must consist largely in the adoption of 
prophylactic measures. The underclothing should be of flannel at all 
seasons of the year — lighter in summer, and heavier in winter. Copious 
perspiration should be avoided, and if that is not possible sudden re- 
frigeration must be prevented. Great relief can be procured from the 
use of salicylic acid and other remedies that are beneficial in acute and 
chronic rheumatism. It is especially important to secure regular daily 



ALCOHOLISM. 681 

movement of the bowels, and to stimulate the kidneys by the judicious 
use of diuretics. Sulphur and cream of tartar, dilute nitric acid, 
dilute phosphoric acid, citrate of potassium, and the salts of lithium are 
among the most efficient agents for this purpose. 



CHAPTER IX. 

ALCOHOLISM. 

Alcoholism signifies that condition which is produced by the intro- 
duction of alcohol into the tissues. It is a mode of intoxication 
quite similar to that by which ptomaines and other products of bac- 
terial activity produce their effects upon the animal organism. In fact, 
alcohol is itself a product of bacterial growth. It exists in all liquids 
that have undergone fermentation, e. (/., beer, wine, and the products of 
their distillation. The quality of these alcoholic beverages varies 
greatly, and the effects which they produce are correspondingly various. 
The least dangerous are those which contain ethyl alcohol unmixed 
with other essences, alcohols, and ethers. For this reason good natural 
wines and beer are less deleterious than cordials, essences, brandies, 
whiskies, etc., that have been fortified and flavored to suit the palate of 
hardened drunkards. 

Alcoholism is more frequent and more severe in northern countries 
where the population are given to the use of distilled liquors. It is less 
common and less severe in southern countries where wine is drank ; but 
among tropical savages who consume distilled spirits, the evil effects of 
alcohol are most conspicuous. 

The susceptibility to alcoholism varies greatly with different indi- 
viduals. Much depends upon the original constitution. It is more 
dangerous among persons of delicate and nervous organization, while 
individuals of a coarse and vigorous fibre, who lead an active life, may 
long withstand the deleterious influences of the poison. Hereditary in- 
fluences not unfrequently determine an appetite for alcoholic beverages, 
and the predisposition to drunkenness may be transmitted from genera- 
tion to generation. In certain cases there is apparently a morbid pre- 
disposition to paroxysmal exhibitions of drunkenness, constituting what 
is termed dipsomania. These cases are closely allied with insanity, 
and constitute a special morbid entity. During the outbreak of a par- 
oxysm of dipsomania, the patient intoxicates himself in a genuinely 
insane and irresponsible manner, and should be restrained like any 
other maniac. 

Alcoholism may occur as a transient event in the life of a healthy 
and temperate person. This constitutes acute alcoholism. It may also 
become a confirmed disease of the entire body as a consequence of the 
long-continued abuse of alcoholic beverages. This condition is termed 
chronic alcoholism. 



682 DISEASES OF NUTRITION. 

Acute Alcoholism. This form of the disease presents itself as a fit 
of intoxication consequent upon a single indulgence. It is characterized 
by an introductory stage of excitement in which all the functions of the 
body are temporarily increased, but are soon merged in disorder that 
terminates in the collapse and stupor of complete drunkenness. The 
effects of such a debauch usually disappear in the course of a few hours. 
The patient awakens with a headache, feels dull and incapable of active 
intellectual exertion, but in the course of a day or two of abstinence 
the normal activities of the brain and nervous system are fully re- 
sumed. 

In severer forms of the disease the mucous membranes of the 
alimentary canal become moderately inflamed, and the liver is irri- 
tated by the passage of blood containing alcohol through its capillaries. 
The symptoms are identical with those of ordinary catarrhal gas- 
tritis. There is a sense of uneasiness in the region of the stomach, 
loss of appetite, great thirst, nausea, sometimes vomiting and diar- 
rhoea. In severe cases a moderate degree of jaundice makes its 
appearance. The tongue is flabby and covered with a pasty coating 
indicative of the extensive disorder of the digestive tract. These 
symptoms gradually subside, and recovery is reached in the course of a 
week or ten days. In warm climates, however, the liver may become 
severely inflamed, and sometimes suppuration may occur within its 
substance. 

In the severest forms of acute alcoholism, death frequently results 
from the profound effect of alcohol upon the brain and nervous system. 
Such accidents are usually witnessed among young children who have 
accidentally drank an excessive quantity of spirits, or among drunk- 
ards who undertake to swallow a bottle of brandy for a wager. The 
victim soon passes into a state of profound unconsciousness that is some- 
times interrupted by convulsive movements. Respiration is stertorous, 
and soon becomes embarrassed by the failure of the respiratory muscles 
and the excessive accumulation of mucus in the trachea. Death occurs 
sometimes in less than an hour, though life may be prolonged for fifteen 
or twenty hours. 

After death alcohol is found free in the blood and in the viscera. 
The mucous membrane of the stomach and intestines exhibits a high 
degree of congestion accompanied by an abundant hemorrhagic infiltra- 
tion of the tissues. The membranes of the brain are intensely con- 
gested, and capillary hemorrhages cover the surfaces of the cerebral 
convolutions. 

Chronic Alcoholism is the result of the long-continued habitual use 
of alcoholic beverages. The persistent though temperate use of them 
produces results more serious than the consequences of an occasional 
debauch. Few habitual drunkards escape damage in some part of 
their structure, but the stomach and the liver are the first to suffer, 
since they bear the brunt of the attack. 

The breath of chronic alcoholism possesses a peculiar, characteristic 
odor. The mucous membrane of the mouth is red and irritated. The 
tongue is covered with a thin white coating, and the organ is sometimes 



ALCOHOLISM. 683 

fissured. The pharynx exhibits the red and roughened appearance 
that is characteristic of granular pharyngitis. The mucous membrane 
of the cesophagus sometimes exhibits erosions, and its veins become 
varicose. The lining of the stomach is in a state of chronic inflamma- 
tion ; in rare instances suppurative inflammation is observed ; the organ 
itself is often relaxed and dilated, but in advanced stages of the disease 
the gastric walls are thickened and indurated. Sometimes irregular 
erosions and ulcerations occur in the mucous membranes. These are 
smaller and more irregular in shape than the typical round ulcer of the 
stomach. 

As a consequence of chronic gastritis the patient suffers with indi- 
gestion, loss of appetite, excessive thirst, nausea, and vomiting. In 
the majority of cases the act of vomiting occurs on arising in the morn- 
ing. After retching and coughing and strangling for a time, a quantity 
of bitter, slimy fluid is ejected from the stomach and throat. It con- 
sists of the saliva and gastric refuse that has accumulated during the 
night. Occasionally little streaks of blood are visible in the gastric 
mucus. 

The intestinal mucous membrane exhibits symptoms of inflammation, 
but they are characterized by a lesser degree of severity than is ob- 
served in connection with the stomach. 

The connective tissue of the liver indicates chronic inflammation and 
contraction, constituting ordinary alcoholic cirrhosis. The hepatic 
cells are compressed by the contracting connective tissue, and pass into 
a condition of fatty degeneration. Sometimes the liver becomes en- 
larged and fatty. In certain cases the effects of alcohol are evident in a 
distinct change of function in the hepatic cells, producing a severe form 
of icterus. 

The inflammatory condition of the pharyngeal cavity frequently 
extends to the mucous membrane of the larynx, producing the hoarse 
and guttural speech that is so characteristic of ancient drunkards. It 
is often accompanied by a laryngeal cough. 

Alcohol does not directly produce diseases of the lungs, but it 
seriously complicates the prognosis in all existing pulmonary diseases. 

The nutrition of the heart is profoundly influenced by chronic alco- 
holism. The muscular substance frequently undergoes degeneration as 
a consequence of disease of the coronary arteries, and myocarditis is 
not uncommon. The arterial structures everywhere exhibit a tendency 
to atheromatous degeneration, and sometimes the portal vein becomes 
inflamed. 

The kidneys are often invaded by interstitial nephritis, and there is 
in many cases a chronic venous congestion of the organs, constituting 
the " pig-back " kidney of alcoholism. 

The sexual functions are profoundly modified ; impotence and dis- 
turbances of menstruation are not uncommon. Abortion frequently 
occurs, and the offspring of drunken parents are frequently epileptic, 
idiotic, or insane. 

Meningeal hemorrhage is not an uncommon event in old cases of 
alcoholism. The arachnoid and pia mater become thickened and ad- 
herent to one another and to the surface of the brain. In alcoholic 



684 DISEASES OF NUTRITION. 

dementia, fatty degeneration and atheroma of the bloodvessels are the 
most characteristic conditions, but in general paresis, the neuroglia is 
principally involved by the sclerotic process. 

The spinal cord does not exhibit any conspicuous change, but the 
tremors that are observed in chronic alcoholism are probably due to 
molecular changes in its structure. 

It is in the peripheral nerves that the most characteristic lesions are 
observed. These will be described in the chapter on peripheral neuritis 
and paralysis. 

Prominent among the disturbances of the brain that are produced by 
chronic alcoholism are simple alcoholic delirium, delirium tremens, 
and alcoholic dementia. It is among debilitated subjects with an un- 
stable nervous organization that delirium is most commonly observed. 
It is characterized by depression and terror. The hallucinations by 
which it is accompanied are of a frightful and agonizing character. 
They are usually connected with the sense of sight. The patient sees 
horrible creatures who surround and attack him, rousing him to a 
violent activity against imaginary dangers by which he is threatened. 
These hallucinations are usually colored by the habitual occupation of 
the patient, and have their origin in his daily associations and pursuits. 
Twilight deepens the intensity of such visions, but they usually disap- 
pear in broad daylight. 

Alcoholic delirium is always accompanied by muscular tremors, 
though in mild cases they are only manifested in connection with vol- 
untary movements. In severe cases the tremor becomes excessive, 
and so incessant that it persists even during sleep. This condition is 
termed delirium tremens. It differs also from simple delirium by the 
fact that the temperature is elevated beyond the normal degree. The 
skin is moist with perspiration ; the breath is offensive ; and intense 
prostration of the entire nervous system is manifested. 

These states of delirium and exhaustion are frequently witnessed 
after a prolonged debauch. They may occur as complications in the 
course of acute diseases, or after injuries, surgical operations, etc., 
especially if the patient be suddenly deprived of his accustomed 
stimulant. 

Alcoholic dementia constitutes the terminal condition of cerebral 
degeneration in chronic alcoholism. It is the result of extensive and 
progressive degeneration of the brain. The last developed and most 
complicated functions of the organ are first abolished. The moral 
sense becomes obscured ; the intellectual faculties fail ; imagination 
disappears ; memory weakens ; speech becomes hesitating and embar- 
rassed ; sensation is blunted ; the power of movement is diminished, 
and the unhappy victim sinks into a condition of vegetative life, inter- 
rupted only by occasional brief paroxysms of delirium or of maniacal 

The skin frequently shares in the ruin that is wrought by chronic 
alcoholism. The red face, swelled nose, and fiery cheeks adorned with 
pustules of acne, are familiar sights in every jovial gathering of con- 
firmed drunkards. Eczema is a common form of eruption, and all 
cutaneous diseases, whether syphilitic or simple in their character, are 



ALCOHOLISM. 685 

greatly aggravated and rendered more intractable when complicated 
with alcoholism. 

The characteristic symptoms upon which the diagnosis of chronic 
alcoholism is based are nausea and vomiting on arising in the morning, 
delirium of a depressing and terrifying character, shooting pain in the 
lower extremities, a feeling of constriction about the calves of the 
legs, partial anaesthesia in different parts of the body, disturbances of 
sight and other organs of special sense. Convulsions usually follow 
the use of absinthe, but they sometimes occur in the later stages of 
severe alcoholism. 

Alcoholism yields a most unfavorable prognosis on account of the 
profound lesions by which it is accompanied. Its effects upon the 
health, well-being, and usefulness of the individual are beyond all 
possibility of estimation. Not only does the victim of intemperance 
suffer in his ow T n person, but his descendants for several generations 
reap the fruits of his folly. Drunkenness, hysteria, epilepsy, mental 
and moral degradation form the pitiable heritage of these unfortunate 
beings. 

Acute alcoholism requires little treatment beyond a favorable oppor- 
tunity for sleeping off the effects of intoxication. In minor forms of the 
disease cold effusions upon the head and back of the neck, accompanied 
by the administration of ten grains of muriate of ammonia, will usually 
give speedy relief. Hence the great virtue ascribed to an acquaintance 
with the village pump after a night at the ale house. 

Chronic alcoholism is seldom curable unless the patient possesses 
sufficient determination to abandon his potations before the establish- 
ment of irremediable disease in the liver and brain. Long seclusion in a 
proper asylum often affords the only effectual means of recovery. The 
diet should be invigorating and easily digestible. Gastro-intestinal 
catarrh requires the ordinary treatment for that disease. Its suppression 
should be the signal for the administration of tonics and restoratives ; 
among these iron, quinine, strychnia, arsenic, and the simple bitters 
are the most effectual. The inordinate craving for stimulants may be 
often effectually subdued by the administration of atropine or other 
solanaceous alkaloids. These should be administered hypodermically 
at intervals of four hours, until the appetite for alcohol is suppressed. 
Pilocarpine may be used at the same time, to counteract excessive dry- 
ness of the mouth. A favorite prescription, in certain quarters, consists 
of the following formula : 



R . — Daturin. sulph 

Strych. nitrat 

Acid, boracic 

Aq. destillat 

S. — Five to ten minims, hypodermically, every foui 



. gr. viij. 
• ?ij—M. 

hours. 



At the same time the patient is instructed to take, every two hours, 
a teaspoonful of the following mixture : 



R . — Tr. cinchon. co. 

Aur. et sod. chlorid. 
Amnion, chlorid. 
A loin. 
Syr. simpl. 



5iv. 
gr. ss, 

.Si v.— M. 



686 DISEASES OF NUTRITION. 

Delirium tremens requires careful nursing and constant watching of 
the patient. Milk, broth, and eggs should be abundantly furnished, 
and capsicum may be given as a cardiac tonic. For the relief of ex- 
haustion and danger of cardiac failure the following pill will be found 
serviceable : 

R . — Pul. capsici. "j 

Pulv. gum. camphor. V aa gr. j. 

Quin. sulph. J 

S. — One such pill every three or four hours. 

Sulphonal is the safest hypnotic. Opiates should be avoided. Cold 
baths are useful when the temperature is considerably elevated. 



CHAPTER X. 

MORPHINISM. 

Morphinism is that morbid condition which follows the abuse of 
opiates, usually morphine taken hypodermically. The fully developed 
habit constitutes what is termed morphiomania, a state of mind and 
body characterized by an irresistible appetite for opiates. The victims 
of this disease are frequently sufferers from painful disorders for which 
opium or morphine have been employed in order to deaden pain and to 
render life tolerable. The appetite thus formed continues after the cure 
of the original disease. In other cases, however, the habit is acquired 
simply for the purpose of awakening pleasurable sensations. In many 
instances the victims of morphiomania are neurotic subjects who belong 
to a degenerated and degraded stock. They exhibit an uncontrollable 
appetite for other narcotics, such as alcohol, chloral, cocaine, etc. 

So great is the rapidity with which the opium habit may be estab- 
lished that the greatest caution should be exercised in the prescription 
of anodynes for patients whose intelligence may lead them to supply 
themselves after the attendance of the physician has ceased. Not more 
than six or eight months are necessary for the complete establishment 
of the habit. 

The subjects of confirmed morphiomania present a prematurely aged 
appearance. The face is wrinkled, pale, and of a dirty-yellow color. 
The pupils are contracted. The power of volition is greatly enfeebled, 
though the other intellectual faculties suffer comparatively little. If 
deprived of the customary dose, exhaustion, trembling of the limbs, de- 
pression of spirits, and nervous prostration are apparent ; but a renewal 
of the accustomed stimulant relieves all these symptoms, and the patient 
revives once more under the influence of the drug. 

The habitual use of opiates is followed by a dryness of the mouth 
and rapid decay of the teeth. The appetite is diminished, though in 
the later stages of the disease there may be intense craving for all kinds 
of food. Digestion is hindered, and the stomach is embarrassed by 



MORPHINISM. 687 

fermentation, causing numerous painful sensations in the epigastric 
region. Constipation is the rule, though sometimes there is diarrhoea 
and distention of the bowels with gas. 

The pulse is often weak and intermittent ; palpitation of the heart is 
frequent. Respiration is sometimes weak and impeded, especially 
when the drug has been withdrawn for a period longer than usual. 

The urine sometimes contains sugar or albumin. The generative 
faculties are diminished and frequently disappear altogether. Men- 
struation is often greatly disordered. 

When morphine is used hypo dermic ally, the skin exhibits innumera- 
ble marks produced by the puncture of the needle. These sometimes 
cover the entire anterior portion of the body and extremities. Slow 
and painful suppuration often follows the use of needles that have not 
been carefully cleansed. 

The effects of injuries are aggravated, and their cure is retarded, by 
the habitual use of opiates. When attacked by an acute disease the 
morphiomaniac sometimes experiences a form of delirium identical with 
delirium tremens and alcoholism. 

The duration of the morphine habit is usually conterminous with 
life. Chronic opium-eaters finally become profoundly cachectic ; some 
of them die of tuberculosis, others yield to chronic inflammation of the 
kidneys, and death sometimes results from erysipelas or pyaemia, 
caused by infection at the point of puncture. 

There are many points of resemblance between alcoholism and mor- 
phinism. Their development is, however, different. Alcohol first in- 
vades the digestive organs and then destroys the nervous system, while 
the opposite course characterizes the effects of opium. 

Treatment. It is impossible to conduct the treatment of the mor- 
phine habit with any degree of success unless the patient be placed in 
a hospital under strict medical supervision for at least four or six 
weeks. The drug should be reduced gradually at the rate of one-quar- 
ter or one-half of a grain of morphine every other day, and tonics in 
the form of the elixir of iron, quinine, strychnine, and arsenic should 
be administered. Sleep should be procured by the use of sulphonal. 
If the symptoms of acute neurasthenia appear, alcoholic stimulants in 
the form of champagne may become necessary, and sometimes it is nec- 
essary to increase a little the amount of the opiate. Warm baths should 
be given every morning and evening, and they may be followed by a 
cold shower-bath along the spine. Massage is also very useful. After 
the conclusion of the treatment the patient should be sent to a sani- 
tarium or water-cure establishment until his physical vigor is fully 
restored. 

The opium habit is sometimes treated by immediate suppression of the 
drug. This course is speedily followed by great prostration and mis- 
ery, which continue from three to five days. The patient is restless 
and full of pain. Respiration is hurried and the pulse beats very rap- 
idly. The throat burns, and the stomach feels as if wounded or 
scorched. Nausea, vomiting, and diarrhoea follow with all the symp- 
toms of complete prostration. At the end of four or five clays the ap- 
petite for food begins to return. Insomnia and depression still exist, 



688 DISEASES OF NUTRITION. 

and suicidal tendencies are sometimes manifested. There is persistent 
diarrhoea, which, however, should not be treated with opiates or astrin- 
gents. Food should be given frequently in small quantities. It should 
consist of eggnog, chicken broth, milk, and beef-tea. The elixir of 
iron, quinine, and strychnine may be given every four hours, with bis- 
• muth for nausea and diarrhoea. At the end of the tenth day the desire 
for opiates is abolished, but careful nursing and tonic treatment should 
be continued for weeks or months until vigorous health is restored, 
otherwise relapses will occur. 



CHAPTEE XI. 

COCAINISM. 

Cocainism produces an exhausted condition of the heart, that is 
marked by an irregular and rapid pulse. Respiration is accelerated ; 
there is profuse perspiration and diarrhoea. Syncope is not uncommon, 
and the sexual power is often destroyed. The patient loses flesh not- 
withstanding the preservation of the appetite and the power of diges- 
tion. The mental faculties are seriously disordered. Hallucinations 
and illusions are commonly experienced, and involve all the organs of 
special sense. Cutaneous sensibility becomes perverted, so that the pa- 
tient complains of insects creeping upon the skin. Delirium and delu- 
sions of persecution are frequently experienced. Memory fails ; the 
power of volition is enfeebled, and all the intellectual faculties are rap- 
idly degraded. 

The abuse of cocaine is followed by results that are more serious and 
irremediable than the effects of either alcohol or opium. The drug 
should never be employed as a substitute for opiates or other narcotics 
in the treatment of the opium habit. 

The treatment of cocainism must be conducted upon the same plan 
as that which has been already described in the case of morphinism. . 



CHAPTEE XII. 

CHRONIC NICOTINISM. 

The principal poisonous constituent of tobacco is the alkaloid nico- 
tine, which is one of the most potent poisons. Besides nicotine, a 
number of poisonous substances are formed during the combustion of 
tobacco. Among these are hydrocyanic acid, collidine, which gives the 
characteristic odor to the smoke of Havana cigars, and other deleterious 
substances. 



CHRONIC NICOTINISM. 689 

Chronic nicotinism is usually experienced by those who smoke 
cigars, and by cigarmakers who are continually handling tobacco. The 
principal symptoms consist in an impairment of memory, vertigo, mus- 
cular tremor, and neuralgia. Tremor is usually observed in the act of 
writing or in connection with other voluntary movements. Vertigo 
may be occasioned either by disordered digestion or by the direct in- 
fluence of tobacco upon the nervous system. Neuralgia is usually 
experienced in the branches of the brachial and cervical plexuses. 
Sometimes the pain of angina pectoris is closely counterfeited by 
cardialgia having its origin in the tobacco habit. 

The mouth, fauces, and pharynx are usually in a condition of sub- 
acute inflammation when subjected to the repeated influence of tobacco 
smoke. The teeth decay rapidly. When the mucous membrane of 
the larynx is invaded by inflammation, hoarseness and a spasmodic 
cough are frequently experienced. Loss of appetite, acidity of the 
stomach, and difficult digestion are frequent incidents. 

Organic diseases of the heart are not produced by tobacco, but the 
nerves of the organ suffer severely under its influence. The rhythm of 
its pulsations is disturbed, and palpitation, or irregular and inter- 
mittent pulsation, are frequently observed. 

The functions of smell and of taste are considerably impaired by 
the continued use of tobacco. Amblyopia is sometimes experienced. 
The generative functions are greatly depressed, and sometimes result 
in complete impotence. Abortion frequently occurs, and the offspring 
of the victims of the tobacco habit are often debilitated and degraded. 

Treatment. The treatment of chronic nicotinism requires absti- 
nence from tobacco, regulation of the digestive functions, the adminis- 
tration of tonics, iodide of potassium, and alcoholic stimulants in 
moderation. Tannic acid is said to be an antidote to nicotine, hence 
the reputation of coffee, tea, and red wine, as remedies in the treatment 
of nicotinism. 



44 



PART IX. 

DISEASES OF THE KIDNEYS AND 
GENITOURINARY ORGANS. 



CHAPTEK I. 

GENERAL RENAL DISEASES. 

Albuminuria. 

Albuminuria consists in the presence of albumin dissolved in the 
urine. True albuminuria signifies the union of albumin with the 
urine as it is secreted by the kidneys. False albuminuria signifies a 
mixture of albumin with the urine during its transit through the 
urinary passages, where it may be derived from blood, pus, or special 
secretions that contain albumin. Mixed forms of albuminuria may also 
exist in which genuine albuminous urine is still further reinforced in 
the urinary passages by substances that yield albumin. 

True albuminuria exists under two forms : one in which the pres- 
ence of albumin is caused by anatomical changes in the kidneys them- 
selves (renal albuminuria) ; the other is dependent upon special 
conditions of the blood without change in the condition of the kidneys 
(hematogenic albuminuria). 

True renal albuminuria is indicated by the presence of renal casts 
and tubular epithelium. False albuminuria is characterized by the 
presence of albumin in quantity proportioned to the blood, pus, or 
other albuminous constituents which are also present in the urine. 

Varieties of albuminuria. The most common form of albumin is 
serum- albumin, such as exists in the serum of the blood ; but, besides 
this variety, serum-globulin, peptone, propeptone, paralbumin, and 
metalbumin may also be found in certain morbid specimens of urine. 
The following tests for these principal forms will be found useful : 

Tests for Serum-albumin. 

Nitric acid test. If the specimen to be examined be turbid, it should 
be filtered ; or, if that be insufficient, it should be shaken with magnesia 
before it is filtered. If it contain oil, after the addition of a small 
quantity of caustic potash or soda, it may be shaken with ether, which 
will remove the oil. 



692 DISEASES OF GEXITO-URIX AK Y ORGANS. 

Having thus prepared a clear and limpid urine, a test-tube may be 
filled to about one-fifth of its depth with urine, which must then be 
heated to the boiling-point and treated with about one-fifth of its vol- 
ume of nitric acid, by which the albumin will be precipitated in a flaky 
mass; or, if present in small quantity, will appear as a faint, white 
cloud. If the urine be neutral, or only slightly acid, it will be clouded 
by heat, in consequence of the expulsion of the carbonic acid gas by 
which earthy phosphates were held in solution ; but upon the addition 
of nitric acid, the phosphates are again dissolved and disappear, while 
the albumin becomes even more apparent. When alkaline urine that con- 
tains albumin is heated, albumin is not necessarily precipitated, since 
it forms a soluble alkali- albuminate which, however, will be precipitated 
by the addition of nitric acid. 

After swallowing balsamic preparations, such as oil of turpentine, 
balsam copaiva, etc., a precipitate of resinous matters will be produced 
by the addition of nitric acid, even though albumin be wanting. The 
addition of alcohol promptly clears up such a precipitate. 

Another method of employing the nitric acid test consists in the 
gradual addition of filtered urine to nitric acid in a test-tube, down one 
side of which the urine is made to trickle, drop by drop, until it forms 
a layer above the acid. At the point of contact between the two 
liquids will appear a white ring of albumin. A layer of urinary 
pigment is sometimes developed immediately above and below the layer 
of albumin. 

Acetic acid test. To urine that has been boiled in a test-tube, acetic 
acid may be cautiously added, when, if albumin be present, it will be 
precipitated, as in the previous test with nitric acid. If an excess of 
acetic acid be employed, a soluble acid-albumin is formed which remains 
invisible in the urine. 

Picric acid test. The addition of concentrated picric acid to filtered 
urine causes a precipitate of albumin. A somewhat similar precipitate 
also appears if quinine or potassic salts are present in the urine. Pep- 
tone is also precipitated by picric acid, but is again dissolved if the 
mixture be subjected to a boiling temperature. 

Metaphosphoric acid test. A small quantity of glacial metaphos- 
phoric acid should be dissolved in distilled water and added to filtered 
urine in a test-tube, when albumin, if present, will appear as a white 
cloud. This test has the advantage of producing the precipitation of 
peptone as well as albumin. 

Ferro-cyanide of potassium and acetic acid test. Having mixed 
equal parts of filtered urine and a saturated solution of ferro-cyanide 
of potassium in a test-tube, acetic acid may be added, drop by drop, 
when the presence of albumin will be indicated by the appearance of a 
white cloud. 

Sulphate of sodium and acetic acid test. To equal parts of filtered 
urine and a saturated solution of the sulphate of sodium, add acetic 
acid, drop by drop, until the mixture gives a decidedly acid reaction ; 
then, on the application of heat, albumin, if present, will be precipitated. 

Trichloracetic acid test. A crystal of trichloracetic acid may be 
shaken with filtered urine in a test-tube ; as soon as the crystal begins 



GENERAL RENAL DISEASES. 

to dissolve, albumin will be precipitated around it in the form of a 
white cloud. 

Numerous other tests may be found described in various works on 
Physiological Chemistry. 

Test for paraglobulin. If urine be saturated with sulphate of 
magnesium, paraglobulin, if present, will be precipitated and can be 
removed by filtration, after which process the filtrate may be tested by 
the ordinary methods for serum- albumin. 

Test for propeptone. To urine that has been boiled and cooled, on 
the addition of acetic acid or nitric acid, if propeptone be present, a 
cloudy precipitate will appear, which will again disappear if the urine 
be heated. 

Test for peptone. Peptone is not precipitated from warm urine by 
the addition either of nitric acid, acetic acid, or ferro-cyanide of potas- 
sium and acetic acid. But, if the urine be treated with alcohol, or 
with metaphosphoric acid, or with picric acid, peptone, if present, will 
be precipitated, and will impart a violet color to an alkaline solution of 
sulphate of copper. 

The quantity of albumin which may be discharged each day, through 
the urine, presents great variations. In certain cases only a trace can 
be discovered, while in others a full ounce may thus be lost. The most 
convenient method of ascertaining the percentage of albumin in a 
given quantity of urine, is afforded by the use of Essbach's albu- 
minometer. This little instrument consists of a test-tube which is 
provided with a rubber cork, and is graduated in such a way that equal 
quantities of urine and the reagent may be readily measured. The 
tube should be filled with filtered urine to the letter U. It is then 
filled up to the letter R with a solution which consists of 10 parts of 
picric acid, 20 parts of citric acid, and 1000 parts of water. The tube 
should be tightly corked and thoroughly shaken, when albumin, if 
present, appears in the form of a more or less dense cloud, that is 
gradually precipitated to the bottom of the tube. The lower portion of 
the tube is graduated in divisions which are numbered from J to 7. 
These divisions correspond to the number of grammes of albumin 
which are contained in a thousand cubic centimetres of the urine that 
is subjected to examination. If, after standing for twenty-four hours, 
the column of albumin reaches figure 3, it indicates three grammes of 
albumin in a thousand cubic centimetres of the urine, or 0.3 per cent. 
If the urine contains more than 0.7 per cent., it must be diluted with 
an equal quantity of water, and the percentage of albumin may then 
be obtained by doubling the product that is indicated upon the gradu- 
ated measure. 

Causes of Albuminuria. In many instances a small quantity of 
albumin can be found in the urine of healthy individuals, constituting 
what is termed physiological albuminuria. This sometimes appears 
after eating eggs, or other articles of food that are rich in albumin. It 
is sometimes present as a consequence of mental depression, or after 
cold baths, or considerable sexual excitement. It is not uncommon for 
a short time at the commencement of puberty. It may follow copious 
perspiration, and it is sometimes observed as a periodical event, occur- 



694 DISEASES OF GEXITO-U RIX AR Y ORGANS. 

ring in successive cycles for a long period of time. The cause of such 
physiological albuminuria is not clearly understood. 

Albuminuria is frequently observed during the course of infective 
fevers and other febrile conditions, when the temperature is for a con- 
siderable time greatly elevated. It is not improbable that in such cases 
the direct action of infective microorganisms, or their products, upon 
the kidneys, determines the appearance of albumin. 

Nervous albuminuria is sometimes observed in association with severe 
diseases of the nervous system, especially those which are attended by 
delirium and convulsions. 

Albuminuria is a not uncommon incident in the course of cutaneous 
diseases, maladies that are attended by great loss of blood, anaemia, and 
cachexia. It is also observed as a consequence of poisoning with lead, 
or the mineral acids, alkalies, phosphorus, cantharides, chromic acid, 
morphine, chloroform, carbolic acid. etc. It follows the development 
of obstructions in the course of the circulation ; it also results from 
diseases of the kidneys, or obstruction in the urinary passages. 

The principal source of urinary albumin is located in the glomeruli 
and in the epithelium of the convoluted tubules of the kidneys, since 
one of the functions of the epithelial cells in the glomeruli, and to a 
certain extent in the convoluted tubules, consists in the prevention of 
the passage of albumin from the blood into the urine. Every cause, 
therefore, that impairs the structure and functional efficiency of those 
epithelial cells favors the discharge of albumin. Changes in the blood 
pressure and alterations in the quality of the blood itself, favor the 
occurrence of albuminuria. 

Treatment. In all forms of albuminuria, dietetic and hygienic 
measures are of the greatest importance. The patient must be warmly 
clothed, and must avoid chilling the surface of the body. Cold baths 
are injurious, but warm baths may be frequently enjoyed with great 
advantage. All excessive exertion and copious perspiration should be 
avoided ; and, during cold weather, a warm climate may be recom- 
mended for those who can change their residence. The diet should 
consist chiefly of milk, fatty substances, and eggs. Strong tea, coffee, 
spices, and alcoholic beverages must be forbidden ; red wine may be 
permitted in moderation on account of the tonic properties which are 
conferred upon it by the presence of tannin. Of internal remedies, 
tannic acid and aloes are among the most valuable. 

R. — Acid, tannic 9ijss. 

Aloin. gr. iij. — M. 

Ft. pil. no. c. 

S. — Four pills after each meal. 

Haematuria. 

Hematuria is indicated by the presence of red blood-corpuscles in 
the urine. This differs from hsemoglobinuria, in which only the 
haemoglobin of the blood is present. 

Hcematuria is a symptom which may follow wounds or injuries of 
the kidneys, or may accompany the intoxication that is produced by 
certain drugs, e. </., cantharides, oil of turpentine, and, occasionally, by 



GENERAL RENAL DISEASES. 



695 



the ingestion of other remedies. It also appears in the course of many 
infective diseases, notably in the course of severe forms of malarial 
fever. It is observed in blood diseases like scurvy, purpura, and 
haemophilia. It often results from embolisms, or thrombi, or aneurisms, 
or blood stasis, affecting the renal vessels. It accompanies inflamma- 
tions and neoplasms in the renal tissues. Parasitic invaders, such as 
echinococcus, distomum haematobium, and filaria sanguinis, frequently 
occasion hematuria. It also accompanies tuberculosis and calculi in 
the renal pelves. 

Hematuria is frequently observed in association with diseases or 
calculi within the bladder. Inflammation and ulceration of the mucous 
membrane of the bladder, and varicosity of the veins of the bladder, are 
often the cause of a bloody discharge with the urine. 

When blood escapes from the urethra, it is, usually, in consequence of 
wounds or injuries which have been inflicted upon its mucous membrane. 

Notwithstanding these numerous causes, many cases of hematuria 
exist without any apparent cause that admits of discovery. 

Symptoms. Hematuria is indicated by a change in the color of the 
urine and by the discovery of red blood-corpuscles in that liquid. 
Small quantities of blood cause the urine to appear like water in which 
raw meat has been washed, while a large quantity changes the color to 
a smoky or coifee-black color. When the blood proceeds from the 
urinary passages, the color of the urine may remain unchanged, be- 
cause the blood is then deposited in the form of a clot. The reaction of 
the urine is generally acid, unless a large quantity of blood from the 
bladder be mixed with it. If the alkaline reaction be due to a vola- 
tile alkali, red litmus paper which has been turned blue by the urine 
will resume its red color on drying ; otherwise the alkaline reaction is 
due to the presence of fixed alkalies. 

Fig. 128. 




Pus corpuscles, a. Without reagents, b. After the addition of acetic acids. (Roberts.) 



When the urinary sediment contains blood clots, they generally pro- 
ceed from the pelves of the kidneys, or from the ureters, and may exhibit 



::5z^szs :? }:y:::-:?.:::A:.T :• ?. -s a >" 5 . 

a vermiform appearance which indicates their source. Hemorrhage 
from the bladder is indicated by the formation of large clots, such as 
_ :-e observed in blood that is rapidly poured out from any other 
source. In doubtful cases, microscopical examination of the urinary 
sediment will readily detect the presence of red blood-corpuscles which 
are either swelled and spherical, or denticulated like the fruit of the 
stramonium plant : numerous microcytes are also present. (P .-. 128. 
In certain cases, amoeboid movements of the red blood-corpuscles can 
be perceived. A change in the color of the corpuscles also frequently 
: ::urs. 

When hematuria originates in the kidneys the blood corpuscles are 
by associated with casts upon which the corpuscles and haematoidin 
crystals are frequently deposited. 

For accurate details with regard to spectroscopic investigation of the 
urine, the student is referred to the larger manuals and works on phys- 
iological chemistry. 

A very convenient test for the presence of blood in the urine is 
furnished by the following method : To a small quantity of urine in a 
test-tube may be added one-third of its volume of a solution of caustic 
potash (1 : 3). On heating the mixture, earthy phosphates of a clear 
gray color will be precipitated. If blood be present, the haematoidin of 
the blood corpuscles will be liberated and will be carried down with the 
phosphates, which will then present a reddish-brown or ruby-red color. 
The precipitate is, moreover, dichroic, appearing red by reflected light. 
and greenish by transmitted rays. If the urine be alkaline before the 
application of the test, it should be mixed with an equal volume of 
healthy acid urine, after which the reaction will prove successful. 

Another test for the presence of blood consists in the addition of two 
drops of tincture of guaiac to a small quantity of urine in a test-tube. 
To the mixture should be added a few drops of turpentine that has been 
ozonized by exposure to the air. If blood be present, a distinct blue 
color is developed when the contents of the test-tube are shaken to- 
gether. 

Dll .-:" :- Hcematuria will be readily recognized by the symp- 
toms which have been already described. It must be distinguished 
from the concentrated urine that accompanies fever and blood stasis ; 
also from the urine of jaundice, which is discolored by the preset, 
biliary pigment : and from urine that is altered by carbolic acid, or by 
the use of rhubarb, senna, fuchsine. or haematoxylin. Malingerer- 
hysterical persons sometimes attempt deception by the addition of blood 
to their urine. 

Renal hcematuria may be distinguished from hematuria which origi- 
nates in the lower urinary passages by the intimate mixture of the 
blood with the urine, and by the facts that a larger amount of albumin 
is present than could be referred to the blood corpuscles themselves, and 
that casts may also be discovered in the sediment. 

Hemorrhage from the pelvis of the kidney and from the ure: 
generally indicated by the appearance of vermiform clots. Hemorrhage 
from the bladder is attended by pain in that organ, by frequent mictu- 



GENERAL RENAL DISEASES. 697 

rition, and by the presence of large clots or the detritus of broken-down 
tumors when neoplasms or calculi have invaded the bladder. 

Hemorrhage from the urethra may be readily discovered by pressure 
upon the walls of the canal and by the appearance of small quantities 
of blood at the commencement of the act of micturition. 

Treatment. The treatment of hematuria must be guided princi- 
pally by the consideration of its causes. The patient should remain 
quietly in bed, and may receive a hypodermic injection of the fluid ex- 
tract of ergot three times a day. Styptics may be administered inter- 
nally, as in other cases of hemorrhage. 

Hemoglobinuria. 

Etiology. Hemoglobinuria is characterized by the presence of 
haemoglobin in the urine. Its source is within the bloodvessels, where 
the blood corpuscles have undergone dissolution, and the resulting pig- 
ment is left for excretion by the kidneys. This may occur as a conse- 
quence of poisoning with sulphuric acid, or hydrochloric acid, or sul- 
phuretted hydrogen, or chlorate of potassium, or pyrogallic acid, or 
carbolic acid, or various other substances. It sometimes occurs in 
connection with severe jaundice, and it may be produced by extensive 
burns, or by the transfusion of blood from the lower animals. It fre- 
quently occurs in connection with infective diseases, and with hemor- 
rhagic diseases of the blood, such as scurvy, purpura, etc. It has been 
witnessed as a consequence of fatty embolism after fractures of the bones. 

In many instances, however, no apparent cause can be discovered. 
Sometimes it occurs paroxysmally (paroxysmal haemoglobinuria). 

Symptoms and Diagnosis. Hemoglobinuria may be recognized by 
the color of the urine, and by its coagulation, when heated, with the 
formation of large albuminous clots that float upon the surface and are 
stained with blood pigment. Microscopical investigation of the uri- 
nary sediment, in haemoglobinuria, indicates the presence of minute 
granules of precipitated haemoglobin, together with hyaline and fatty 
renal casts and epithelial cells which are stained with blood pigment. 
Crystals of haematoidin and uric acid are frequently present. 

Melanuria. Melanuria is observed in cases where melanotic tumors 
exist in some portion of the body. 

Glaucosuria signifies the presence of indican in the urine, by which 
the liquid is colored a dark purple hue, and deposits a sediment of in- 
digo blue. 

Chyluria has already been described in connection with its parasitic 
cause — filaria sanguinis hominis (p. 80). 

Lipuria is indicated by the presence of oil which appears in circular 
films upon the surface of the urine. This occurs, sometimes, after ex- 
cessive use of fats and oils, or in the course of diabetes mellitus, or 
diseases of the pancreas, or of the heart, or chronic diseases that favor 



DISEASES :i GEJTITO— UBINAEY ORGANS. 

amyloid degeneration. It also occurs during pregnancy, or as a con- 
sequence of poisoning with phosphorus or coal gas. and after fractures 
whiei. : don the formation of fatty emboli. It may also occur in the 
course of acute fatty _ of the liver and kidneys. 

Fibrinuria signifies the presence rf fibrin in the urine to an extent 
that produces its coagulation after the liquid has been voided. It 
usually occurs in the course of villous cancers of the bladder, or after 
the use of can:, ri s It is said to be endemic in Ms _ scar and in 

Brazil. 

Hydrothionuria consists in the presence of sulphuretted hydrogen in 
the urine. The source of the gas may be sometimes referred to the 
alimentary canal. 01 tc >erit neal ibseesses in which : : .t:: d virion has 
taken place. 



CHAPTER II. 

DISEASES OF THE RENAL PABENCHYMA. 

Ischaemia of the Kidneys — Ischaemia Renalis. 

Etiology. The structure and function of the kidney are dependent 
upon the integrity of :: 1 supply. Any deficiency in this respect 

: si ons alteration in the nutrition of the epithelial cells in the con- 
voluted tubules and glomeruli. Cloudy swelling and fatty degenera- 
tion follow, by reason of the deficient supply of oxygen to which they 
are subjected. The escape :: albumin from the blood follows as an im- 
te consec nenoe :: this structural deterioration. The most perfect 
examples of renal tnessed in the course of cholera and 
of pregnancy, though minor forms of the same disorder exist in connec- 
tion with exhausting diarrfa r sudd rrhages, and in diseases 

which : non great reduction in the number of red blood-corpusdc 
of their litem: _ sis, leukaemia, progressive pern: 

anaemia, cancer, syphilis, malaria, tuberculosis, etc. 

Every condition that favors the development of arterial spasm. - 
lead colic, epilepsy, tetanus, colic, and eclampsia, may cause the renal 
structure to suffer from an insufficient supply _L the 

occurrence of arterial spasm. 

Pathological Anatomy. In typical cases the kidney often 
appears enlarge I; its Burface is smooth, and it is softened. The corti- 
cal portion is increased, and is of a pale yell . while the medul- 
lary portion exhibits a state of hyperemia. The epithelial cells of the 
tubules show the signs of fatty degeneration. 

S MPT0M8. mptoms depend upon the degree and duration of 

ischemia. The urine is U in quantity, and exhibits the presence 

of albumin an I sts. The subcutaneou- tissues t, - 



DISEASES OF THE RENAL PARENCHYMA. 699 

times even before the appearance of albuminuria ; in other cases oedema 
is entirely absent. The urine is diminished in quantity, and its specific 
gravity is increased, but the amount of albumin rarely exceeds two 
parts in the thousand. In cases of pregnancy its quantity is usually 
greatest at the time of parturition. Hyaline casts, often covered with 
minute oil globules, and tubular epithelium may be found in the 
sediment. 

The duration of the disease is variable, and when associated with 
pregnancy, may soon disappear after parturition, rarely resulting in 
Bright's disease. 

Among the most serious complications must be reckoned eclampsia. 
Convulsions are sometimes preceded by vomiting, diarrhoea, headache, 
etc.; but, sometimes, they occur without warning, during a condition of 
coma. It should not be forgotten, however, that convulsions during 
pregnancy are not always dependent upon renal disease. Opinions are 
also divided with regard to the cause of convulsions, whether it consists 
in the retention of urinary constituents, or in an anaemic and cedema- 
tous condition of the brain. 

Diagnosis. In cases of pregnancy it must be carefully considered 
whether the disorder is dependent upon simple renal ischaeniia, or 
whether the pregnant condition was not preceded by a diffuse nephritis 
that may terminate in Bright's disease. 

Prognosis. The prognosis is favorable in cases of simple ischaemia. 

Treatment. The treatment depends upon the cause of ischaemia. 
Iron and quinine should be administered in cases of anaemia during 
pregnancy. Eclampsia requires the hypodermic administration of 
morphine, and the inhalation of chloroform, or the use of clysters con- 
taining chloral. Parturition should be terminated as quickly as possi- 
ble. Whether premature delivery should be effected, is still an open 
question. 

Venous Hyperaemia of the Kidneys. 

Etiology. Renal stasis occurs whenever the renal veins are in any 
way obstructed. This usually follows diseases of the organs of circu- 
lation and respiration ; in other words, whenever the exit of blood 
from the right side of the heart is impeded. 

In certain cases the impediment may be caused as a local obstruction 
by thrombosis in the renal veins, or in the course of the inferior vena 
cava. 

As a consequence of blood stasis, the arterial supply of the kidneys 
must necessarily be reduced ; consequently the amount of urine that is 
secreted is also diminished. 

Pathological Anatomy. The kidney is unusually large, and 
presents a purple color. The capsule is tense, transparent, smooth, 
and can be easily stripped from the organ. The stellate veins upon 
the surface appear distended, and minute extravasations of blood are 
sometimes visible. The parenchyma is firm and resistant, and of an 
unusually dark color. The glomeruli are frequently visible in the form 
of dark-red points. The total condition is often indicated by the term 
cyanotic induration of the kidneys. 



700 DISEASES OF GEXITO-UEIXAEY ORGANS. 

After a time the kidney undergoes atrophy. The color changes to 
a lighter tint, but the density of the organ increases. The thickness 
of the cortical portion diminishes, and the capsule becomes adherent, 
or cannot be stripped off without lacerating the subjacent structure. 
The tubular epithelium, especially in the convoluted tubules, exhibits 
cloudy swelling and fatty degeneration. The glomeruli and the tubules 
are sometimes filled with extravasated blood or pigment. Hyaline casts 
are also visible. In an advanced stage of the disease the connective 
tissue is greatly increased in amount, and the glomeruli appear thick- 
ened. The tubules may be destroyed by degeneration and loss of their 
epithelium, which produces atrophy and contraction of the cortical por- 
tion of the organ. 

Symptoms. The urine is diminished in quantity, and its specific- 
gravity is increased to 1030 and upward. On cooling, a sediment of 
urates is deposited which contains round cells, occasionally, blood cor- 
puscles, and epithelium from the bladder and urinary passages. Hyaline 
casts, with adherent oil globules and tubular epithelium, are frequently 
present. Albuminuria is often absent ; when present, its quantity is 
small. 

Since the renal disease is dependent upon blood stasis which has its 
origin elsewhere, the symptoms of obstructed circulation in other 
organs will be observed. Dyspnoea, cyanosis, palpitation, and cedema 
are frequently developed. 

Diagnosis. From actual nephritis renal hyperemia is differentiated 
by the frequent absence of albumin from the urine, or by its small 
quantity when present. Casts are less numerous than in cases of ne- 
phritis. If any considerable quantity of blood be apparent in the urine 
in connection with cardiac diseases, the possibility of renal embolism 
should not be neglected ; the embolic process is indicated by violent 
pain in the kidneys, chills, fever, and vomiting. 

Prognosis, the prognosis is not unfavorable so far as the kidneys 
are concerned, though the underlying causes are often associated with 
great danger. 

Treatment. The dependence of the disease upon cardiac debility 
is so common that treatment must be principally addressed to the in- 
vigoration of that organ. For this purpose nutritious diet, wine, and 
digitalis or its substitutes, may be recommended (p. 542). Diuretics 
must be administered when the quantity of urine is considerably dimin- 
ished ; for this purpose may be recommended the aerated mineral 
waters, citrate of potassium, squills, and juniper. 

R. — Syr. scilla? las. 

Potass, curat 5J. 

Aqua? Oj- — M. 

S. — A tablespoonful every two hours. 

Calomel given in doses of two grains every four hours, greatly increases 
the diuretic effect of digitalis. Purgatives are useful for vigorous per- 
sons, but diaphoretics must be employed with great caution, since they 
may induce faintness and palpitation is cases of cardiac or pulmonary 



DISEASES OF THE RENAL PARENCHYMA. 701 

disease. Debilitated patients require stimulants and tonics, such as 
valerian, camphor, and the compound tincture of cinchona. 

Diffuse Inflammation of the Kidneys — Morbus Brightii. 

BrigMs disease is a term that is applied to inflammations of the 
kidneys which involve their entire structure. The disease may be either 
acute or chronic ; acute inflammation may pass gradually into the 
chronic form, but chronic inflammation often begins independently as 
such. 

Renal inflammation is by no means limited to any special tissue of the 
organ, but it may manifest itself more conspicuously in one tissue than 
in another, according to the circumstances of the case. The terms 
parenchymatous inflammation and interstitial inflammation merely 
indicate the predominance, in the one case, of inflammation in the paren- 
chyma, while, in the other, it is the connective tissue that principally 
suffers inflammatory change. In a third class of cases, both tissues may 
be equally involved. 

Under the general term, Bright's disease, are therefore included 
acute and chronic inflammations of the renal parenchyma, and chronic 
interstitial inflammation of the renal connective tissue. 



Acute Parenchymatous Inflammation of the Kidney — Nephritis 

Acuta Diffusa. 

Etiology. Acute nephritis frequently occurs in association with epi- 
demic infective diseases, especially after scarlet fever and diphtheria. It 
is more common in cold and damp climates than in mild and equable regions, 
and is often observed after exposure to sudden chills. It sometimes 
follows injuries and excessive exertion. It may be produced by exces- 
sive use of alcohol, or by acrid diuretics like squills, oil of turpentine, 
and resinous preparations. Nitrate and chlorate of potassium, salicylic 
acid, the mineral acids, phosphorus, arsenic, and lead, have been known 
to excite renal inflammation. Excessive cutaneous irritation, such as 
may be produced by blisters or irritating inunctions, sometimes pro- 
duces inflammation of the kidneys. Its connection with infective dis- 
eases, syphilis, consumption, and malarial poisoning are well known. 
In certain cases, the capillary loops within the glomeruli have been 
found occluded by emboli that were composed of micrococci. It is 
probable that if the microorganisms themselves do not excite inflamma- 
tion, their products and excretions which enter the kidneys are suffi- 
cient to produce the disease. Acute nephritis is also associated with cer- 
tain cases of dyscrasia, e. g., scurvy, purpura, etc. It may also occur 
as a secondary consequence of inflammation involving the urinary 
passages. The existence of cardiac disease exercises a favoring effect 
upon its development. 

Pathological Anatomy. The changes that are produced in the 
structure of the kidney sometimes require the aid of the microscope 
for their demonstration. When visible to the naked eye they produce 
an unusual enlargement of the organ. Its capsule appears smooth and 



702 



DISEASES OF GE XI T O-U B IN A B Y ORGANS 



tense ; the stellate veins are very conspicuous upon its surface, and the 
bloodvessels are everywhere distended with blood. The cortex appears 
purple, and the glomeruli are distinctly visible in the form of minute 
and prominent granules that are filled with blood : very frequently hem- 
orrhagic extravasation may be discovered in the cortex. So conspicu- 
ous are the evidences of congestion that this form of renal inflamma- 
tion is distinguished by the term large red kidney. 

In other cases, the inflamed kidney, though enlarged, appears of a 
pale-yellow color, constituting what is termed the large white kidney . 
Its substance is traversed by yellow streaks which indicate local fatty 
degeneration. Hemorrhagic points are in certain cases visible upon 
the surface of the organ and within its substance. It is probable that 
this variety of inflammation exists independently, and it does not rep- 
resent the later stage of the previous variety, though it is possible that 
this may sometimes occur. 

In certain cases microscopical examination reveals the fact that in- 
flammation is restricted almost exclusively to the glomeruli ( Glomerulo- 

Fig. :; 




Scarlatinal nephritis, fourth day. Cortical section, a. Intracapsular hemorrhage- 
passing into tubule, b. Cloudy swelling of tubular epithelium, c. Intertubular hemor- 
rhage, d. Intratubular hemorrhage. (PrRDY.) 



nephritis). (Fig. 129.) This is frequently observed after scarlet fever. 
In <,ther cases the interstitial connective tissue is infiltrated with round 
cells : in others, especially after diphtheria, the epithelial cells of the 
tubuli uriniferi are principally affected by inflammation. Vascular 



DISEASES OF THE RENAL PARENCHYMA. 



703 



changes, inflammatory oedema of the connective tissue, and its infiltra- 
tration with round cells are common incidents. Hemorrhagic effusions 
are usually observed in the glomeruli or in the tubuli uriniferi, rarely 
in the connective tissue. Sometimes the pigmentary debris of previous 
hemorrhages can be observed in the tubules, or in the connective tissue. 
The epithelium of the convoluted tubules soon loses its cilise, becomes 
granular and swollen, and finally undergoes fatty degeneration. (Fig. 
130.) The tubules are thus considerably obstructed, and much more 

Fig. 130. 




Scarlatinal nephritis, third week. a. Tubule from which epithelium has been ex- 
foliated, b. Desquamated epithelium of Bowman's capsule, c. Compressed tuft. d. 
Cast in tube seen in cross-section. (Purdy.) 



so when the softened epithelial cells are exfoliated into the passages 
(desquamative nephritis). Sometimes the epithelium is pushed off 
from the basement membrane of the tubules by a granular exudation 
of albumin. (Fig. 131.) The cells are deformed and heaped together 
with round cells and free nuclei in the tubules (catarrhal nephritis). 

The urinary passages frequently share in the inflammatory process. 
General dropsy is also a very common event, and the heart becomes 
dilated and hypertrophied. 

Symptoms. Acute nephritis frequently commences in a very insid- 
ious manner. In many instances it has been preceded by a trifling 
attack of scarlet fever or diphtheria ; in other cases it begins suddenly 
with chills and fever, vomiting, loss of appetite, constipation, and 



704 



DISEASES OF GENITO-URINARY ORGANS. 



headache ; sometimes there is pain in the region of the kidneys ; in a 
short time the skin becomes pale, and the evidences of disordered health 
are apparent. In many cases fever is absent, and dropsy forms the 
first symptom that attracts particular attention ; this usually disap- 
pears during the night, but reappears during the course of each day ; 
considerable reduction in the amount of urine is accompanied by cor- 
respondingly rapid increase of dropsical symptoms ; albumin is almost 
always found in the urine under such circumstances ; during the course 
of the disease the quantity of urine is greatly reduced, and the secre- 




Acute nephritis. Transverse section through cortex, a. Hyaline cast within con- 
voluted tube. b. Cross-section of tubule containing granular cyst. c. Degenerated and 
exfoliated epithelium seen in longitudinal section of tubule. (Pubdy.) 

tion is sometimes entirely suppressed. The commencement of recovery 
is generally indicated by a great increase in the daily discharge. 
Hcematuria is not uncommon, though microscopical examination may 
sometimes be necessary for the demonstration of blood-corpuscles ; 
sometimes blood is only visible in urine that has been voided during 
the day, or after a paroxysm of fever ; blood clots are always absent, 
since the source of hemorrhage is located in the kidneys. The urinary 
specific gravity is increased to 1030 or even higher : the amount of 
albumin is sometimes so great that the urine completely coagulates 
when heated. 

The urinary sediment may contain various crystalline forms which 
possess slight importance in comparison with the red blood- corpuscles, 



DISEASES OF THE RENAL PARENCHYMA. 



705 



round cells, renal epithelium, and casts which are present, together 
with epithelial cells from the urinary passages. In certain cases blood 
casts, epithelium casts, and fat granules are visible. (Figs. 132, 
133, 134). 



Fig. L32. 









Renal epithelium, a. Natural appearance, b. Atrophied and disintegrated renal 
cells, c. Renal cells in a state of fatty degeneration. (Roberts.) 

Fig. 133. 




a. Fatty casts, b. and c. Blood casts, d. Free fatty molecules. (Roberts.) 

As a consequence of the affection of the epithelial cells in the con- 
voluted tubules, the solid constituents of the urine are proportionately 
diminished in quantity, and they increase with the progress of 
recovery. 

When inflammation has been excited by violent irritants like 
cantharides or turpentine, the act of micturition may be attended with 

45 



706 



DISEASES OF GENITO-URIXART ORGAXS. 



great [pain ; and, though the impulse to frequent passage of urine 
exists, only a few drops are voided at a time, constituting what is 
known as strangury. The right heart frequently becomes dilated, 
sometimes to a degree that awakens a suspicion of pericardial effusion. 
The pulse becomes full and tense, though frequently its beats are re- 
duced in number. Acute nephritis continues from one to two weeks. 
Convalescence is attended by gradual reduction of blood and albumin in 




a. Epithelial casts. 



b. Opaque granular casts. From a case or acute 
Bright's disease. (Roberts.) 



the urine, and the daily quantity of liquid that is voided is greatly 
increased ; this is always accompanied by an increase in the amount of 
chloride of sodium which, during the inflammatory period, had been 
retained in the tissues. Recovery is not unfrequently tedious and 
subject to frequent relapses. Casts usually remain visible for a long 
time in the urine. In certain cases the disease passes into the chronic 
form of Bright's disease. 

Besides dropsy, one of the most dangerous complications of nephritis 
is urcemia, which is liable to result from deficient renal discharge and 
the accumulation of urinary constituents in the blood. It is character- 
ized by severe headache and determination of blood to the brain, 
vomiting, difficulty of breathing, and epileptiform convulsions. 

In certain cases acute nephritis presents itself under unusual forms ; 
sometimes the disease runs its course in four or five days ; in other in- 
stances the symptoms are almost identical with those of severe typhoid 
fever; in still a third class of cases the prominent symptoms are those 
of uraemia. An apparently healthy person is suddenly attacked by 
epileptiform convulsions which recur again and again, and which are 
relieved by the return of a healthy condition in the urine and kidneys : 
in other cases the convulsive attacks are replaced by violent delirium 



DISEASES OF THE RENAL PARENCHYMA. 707 

and maniacal symptoms, associated with the urinary changes that are 
characteristic of nephritis. 

Diagnosis. Acute nephritis may be differentiated from venous 
hyper cemia of the kidneys by the absence of cardiac or respiratory 
diseases, and by the more conspicuous presence of morbid constituents 
in the urine. Renal embolism may be distinguished from acute nephri- 
tis by the abrupt development of pain, chills, fever, and vomiting in a 
patient who is suffering with previous valvular disease of the heart. 

It must always be difficult to differentiate acute nephritis from an 
acute exacerbation of chronic renal inflammation ; in such cases the 
history of the patient will often afford much information. 

Prognosis. Acute nephritis is frequently followed by complete re- 
covery, but the disease is attended with so many dangers that the 
prognosis should be expressed with great caution. 

Treatment. The diet must consist chiefly of milk, broth, and tender 
meat ; tea and coffee must be forbidden, since they are irritating to the 
kidneys. The patient should remain warm in bed, and should have a 
warm bath every morning and evening. The bowels must be moved 
every day, for which purpose may be prescribed the compound infusion 
of senna, or the compound licorice powder. If malaria or syphilis have 
occasioned the inflammation, quinine, or mercurial preparations and 
iodine, should be prescribed. For the relief of hematuria and albumi- 
nuria, styptics are of very little value ; leeches and cups have been fre- 
quently employed, but they are generally unnecessary. Diuretics 
should be administered whenever the urine is greatly reduced in amount, 
but all irritating and acrid remedies should be avoided. Mild saline 
diuretics, like aerated waters, citrate and bitartrate of potassium, are the 
most useful remedies. Dropsy may be combated by the administration 
of diaphoretic remedies and hot-air baths. Pilocarpine and morphine 
may be administered hypodermicaily for the purpose of promoting 
perspiration. 



R. — Pilocarpin. hydrochl gr 

Morph. sulph gr 



i 
• w 

1 

TO- 



Aquse 3ss.— M. 

Chronic Parenchymatous Inflammation of the Kidneys — Nephritis 
Chronica Parenchymatosa Diffusa. 

Etiology. Chronic parenchymatous nephritis is usually developed 
as a primary disease. It most frequently occurs between the twentieth 
and fiftieth years of life, and is more common among men than among 
women, in cold and damp climates. In many cases it originates with- 
out any apparent cause, but in other instances it can be directly traced 
to exposure to cold, or to the influence of malaria, or syphilis, or chronic 
wasting discharges. 

Pathological Anatomy. The kidneys are greatly enlarged in size 
and weight. The capsule is dense and easily stripped from the organ, 
which presents a yellowish-gray color. The stellate veins upon the 
surface are locally dilated. The cortical portion is greatly reduced and 
contrasts strongly with the reddened and highly injected medullary 



708 



DISEASES OF G EXITO-U R IX AR Y ORGANS. 



portion of the organ. Yellowish points and streaks are visible in the 
cortex, where they correspond to glomeruli and uriniferous tubules 
which have undergone fatty degeneration. The connective tissue also 
exhibits evidences of inflammatory proliferation. 

Microscopical examination indicates fatty degeneration of the epithe- 
lium, especially in the convoluted tubules. The straight tubules are 
frequently filled with oil globules and with a delicate fibrillar network 
of albuminous material such as may be observed in acute nephritis. 
The epithelial cells of the glomeruli are frequently swelled, increased in 




Chronic nephritis : section of cortex, a. Malpighian tuft somewhat contracted. 6. 
Thickened capsule of Bowman, c. Tubule somewhat compressed, d. Tubule greatly 
compressed, with lumen obliterated. (Pcedy.) 

number, and subjected to fatty degeneration. (Fig. 135.) The capil- 
laries of the glomeruli contain a little blood, and their walls exhibit evi- 
dences of nuclear proliferation, fatty degeneration, and irregular dilata- 
tion. The connective tissue is often involved in the inflammatory pro- 
cess. 

In certain cases the cortex exhibits hemorrhagic effusions of different 
date. The connective tissue of the organ is increased, and many of the 
glomeruli and tubuH uriniferi have disappeared. GJft ; 

Not unfrequently. the large white kidney undergoes contraction 
(secondary contracted kidney) ; this results from a collapse and oblitera- 
tion of the uriniferous tubules and glomeruli, which sometimes undergo 
calcification. The interstitial connective tissue proliferates and under- 



DISEASES OF THE RENAL PARENCHYMA. 



709 



goes contraction, so that the surface of the organ becomes uneven, and 
its capsule cannot be stripped off without lacerating the subjacent tis- 
sues. This form of contraction may be distinguished from the contrac- 
tion which takes place as a primary disease, by the greater prominence 
of the nodules upon the renal surface, and by the fact that cysts are 
rarely formed within its substance. The yellow color of the organ also 
distinguishes it from the red, primary contracted kidney. 

Symptoms. Chronic parenchymatous nephritis often begins with 
all the symptoms of acute nephritis and gradually subsides into a 
chronic form ; but, usually, the disease commences insidiously. Dropsy 
is often one of the earliest symptoms that attract attention, and it 
reaches a greater degree of development than in acute nephritis ; the 
skin becomes pale, digestive disorders interfere with the nutrition of 
the patient, dyspnoea and palpitation occasion distress, death sometimes 
suddenly follows asphyxia or oedema of the lungs or glottis. 



Fig. 136. 




Hyaline, or waxy casts, a. From a case of chronic Bright's disease of eight months' 
duration, b. From a case of chronic Bright's disease (large white kidney), c. From a 
case of chronic Bright's disease (contracted kidney, with fatty degeneration). (Roberts.) 



The amount of urine is greatly diminished, and it is frequently 
turbid with urates ; the specific gravity is increased, and a large amount 
of albumin is present, sometimes exceeding half an ounce each day. 
The urinary sediment contains hyaline, granular, and waxy casts, 
minute oil globules, and cells from the tubules which have undergone 
fatty degeneration. (Fig. 136.) Red blood-corpuscles and round 
cells are sometimes present. Chloride of sodium, phosphoric acid, and 
kreatinin are diminished in amount. 

The pulse is usually small and weak. Hypertrophy of the heart 
occurs less frequently than in chronic interstitial nephritis. 

The temperature of the body usually remains normal. The retina 
is less frequently inflamed than in cases of interstitial nephritis. The 



710 DISEASES OF GENITO-U RIN AR Y ORGANS. 

course of the disease is prolonged for many months or years ; recovery 
rarely occurs. Remissions and exacerbations are not uncommon, 
especially after exposure to cold or unusual exertion. Death fre- 
quently results from serous or pulmonary inflammations, to which the 
disease occasions a predisposition. Erysipelas and gangrene of the 
skin sometimes produce a fatal termination, or it may be brought about 
by exhausting diarrhoea, or uraemia, or cerebral hemorrhage. 

In certain cases the kidneys undergo a secondary contraction; the 
urine becomes more abundant, its specific gravity falls to 1012 or less, 
and its morbid constituents are diminished, but the heart undergoes 
dilatation and hypertrophy. The left ventricle is especially liable to 
this change, but the right side also participates at a later period. 

Diagnosis. The recognition of chronic parenchymatous nephritis 
is frequently attended with difficulty, and from the amyloid kidney it 
cannot be distinguished by the symptoms, unless evidences of amyloid 
degeneration are apparent in other organs. Acute nephritis is differ- 
entiated by its rapid course, acute symptoms, and lesser degree of oedema. 
Chronic interstitial nephritis is distinguished by the usual absence of 
oedema, by the increased quantity of urine of a low specific gravity, 
and by the absence of albuminuria. Interstitial nephritis is also more 
frequently associated with hypertrophy and dilatation of the heart, 
inflammation of the retina, uraemia, and cerebral hemorrhage. When 
the kidneys have undergone secondary contraction their condition may 
be differentiated from primary chronic interstitial inflammation of the 
kidney by the occurrence of dropsy during the earlier stages of the 
disease, by the normal quantity of the urine, which exhibits a specific 
gravity of about 1010, and by the presence of albumin and other 
morbid constituents, among which the evidences of fatty degeneration 
are conspicuous. 

Prognosis and Treatment. The prognosis is always unfavorable. 
The treatment corresponds very nearly with that which has been recom- 
mended in cases of acute nephritis. A milk diet, warm baths, moderate 
diaphoresis, and the use of citrate of potassium as a diuretic afford 
all the relief that can be expected in the majority of cases. 

Chronic Interstitial Nephritis — Nephritis Interstitialis Chronica. 

Etiology. The primary form of chronic interstitial nephritis may 
be considered as one of the diseases of old age. It is usually encoun- 
tered after the fortieth year of life ; more commonly among men than 
among women, especially among those who are exposed to poverty and 
unfavorable climatic influences. The abuse of alcohol, lead poisoning, 
gout, malarial poisoning, syphilis, chronic wasting discharges, chronic 
diseases of the urinary passages, and, in certain cases, unknown hered- 
itary influences, all act as predisposing causes of the disease. 

Pathological Anatomy. Besides the ordinary form of chronic 
interstitial nephritis, a senile form may be observed, which is depend- 
ent upon arterio-sclerosis. 

Senile or arteriosclerotic interstitial inflammation of the kidney 
occurs in old age. Besides other portions of the circulatory apparatus, 



DISEASES OF THE RENAL PARENCHYMA. 



711 



the renal arteries and their branches are involved. The glomeruli 
receive less blood ; the tubuli uriniferi become obstructed, and trans- 
formed into cysts, so that the kidney appears as if invaded by cystic 
growths. The interstitial connective tissue undergoes comparatively 
slight change. The organ appears diminished in size, and its surface 
becomes nodulated, but the tissues are less resistant than in cases of 
ordinary renal contraction. The cortical portion is greatly reduced. 
The genuine 'primary contracted kidney is frequently surrounded by a 



Fig. 137. 




Cirrhosis of the kidney; longitudinal section of the cortex, including capsule, a. 
Thickened capsule, b. Compressed tubule, nearly obliterated, c. Wedge-shaped band of 
dense tissue extending inward from capsule, d. Malpighian tuft somewhat compressed. 
e. Section of artery, showing thickened coats. (Purdy.) 

considerable amount of fat ; its capsule appears more or less generally 
thickened and adherent to the renal parenchyma ; its bloodvessels are 
often greatly dilated. The kidneys themselves are very small, sometimes 
less than half the ordinary size and weight of the organ. The surface 
presents a dark-red color, and is granular and nodulated, in conse- 
quence of irregular contraction of the connective tissue. The breadth 
of the cortical portion is exceedingly reduced, though the medullary 
portion presents less evidence of diminution. The renal infundibula 
and pelvis are dilated, and frequently exhibit the evidences of catarrhal 
inflammation. 

Microscopical examination reveals great increase in the interstitial 



712 DISEASES OF GEXITO-U KIN AR Y ORGANS. 

connective tissue by which the atrophied parenchyma is in many locali- 
ties completely replaced. 

The renal vessels exhibit changes which are, frequently, the local 
manifestations of a general vascular disorder. The tunica intima of 
the arterioles undergoes epithelial proliferation and infiltration with 
round cells, by which the lumen of the vessel is more or less obstructed 
(endarteritis obliterans). Sometimes the remaining arterial coats ex- 
hibit an appearance similar to that of amyloid degeneration, though the 
iodine test fails to identify the exudation. The muscular coat of the 
arteriole is frequently hypertrophied. 

The appearances which are presented by the so-called gouty kidney 
agree with those which have been above described. A deposit and 
infiltration of urates is also observed in the tubuli uriniferi and in the 
intertubular connective tissue. 

Changes similar to those which are observed in the renal arteries also 
invade the other arteries of the body. The heart usually undergoes 
dilatation and hypertrophy ; the endocardium and the pericardium 
also become extremely liable to inflammation or degeneration. The 
pleural and the pulmonary organs are frequently inflamed. The pericar- 
dial sac and the g astro-intestinal canal are often affected by inflamma- 
tion, and ci?Thosis of the liver is a common event. Meningeal disease 
and thickening of the bones of the skull are not uncommon. Cerebral 
hemorrhage or oedema, and anosmia of the brain have been observed. 

Symptoms. Chronic interstitial nephritis frequently runs its course 
with symptoms of so trifling a character that the disease is only recog- 
nized by its termination, or after death. Frequently palpitation, or 
symptoms of cardiac hypertrophy, or of gastro-intestinal catarrh, or the 
occurrence of failure in eyesight or hearing, bleeding at the nose, 
hoarseness, headache, thirst, polyuria, epileptiform convulsions, severe 
neuralgia, or chronic rheumatic pains, are the only symptoms of which 
the patient complains ; and only on examination of the urine is their 
connection with renal disease made apparent. 

The prominent symptoms by which the disease may be recognized 
are three : changes in the character of the urine ; changes in the con- 
dition of the circulatory apparatus ; and changes in the organs of 
vision. 

The quantity of the urine is greatly increased, and the amount that 
is voided at night is greater than the portion voided during the day. 
Only in the later stages, when the heart begins to fail, or when the 
renal structure is nearly consumed, is the amount of urine diminished. 
The color is yellow, the liquid froths easily by reason of its mixture 
with albumin, the reaction is acid, the specific gravity is usually low, 
rarely exceeding 1010 or 1012, and it is not increased by intercurrent 
fever. The amount of albumin is small, and sometimes it is absent 
altogether for a time. There is very little sediment, and it contains 
only a few long, slender hyaline casts, upon which are sometimes de- 
posited minute oil globules, or epithelial cells from the tubuli uriniferi, 
or crystals of the oxalate of calcium. Occasionally round cells and red 
blood-corpuscles are present in small numbers, unless they have under- 
gone increase from an acute exacerbation of the inflammatory process. 



DISEASES OF THE RENAL PARENCHYMA. 713 

The percentage of urinary constituents is almost always reduced, though 
the increased quantity of urine may keep the total balance good. 
Sometimes the amount of urea is greatly diminished, and occasionally 
it is excreted through the medium of the perspiration, appearing upon 
the surface of the skin in the form of a frosty deposit. The other 
urinary constituents are also diminished in quantity. 

Dilatation and hypertrophy of the heart are very common occurrences. 
The pulse is hard and wiry in consequence of the increased tension that 
is produced by hypertrophy of the left ventricle. Palpitation of the 
heart or determination of blood to the head, epistaxis, and cerebral 
hemorrhage are not uncommon consequences of cardiac changes. 

The connection between inflammation of the kidneys and hypertrophy 
of the heart is very certain, yet its causes are not thoroughly under- 
stood. It has been attributed to the increased resistance that is sup- 
posed to follow the occlusion of so considerable an arterial territory as 
the renal circulation ; but cardiac hypertrophy does not follow amputa- 
tion of a limb. Hypertrophy of the heart is probably the result of the 
retention of urinary constituents in the blood, by which the cardiac 
muscle undergoes irritation and modification of structure. 

Attention is frequently directed to the changes within the eye by the 
occurrence of ocular disturbances, such as amblyopia, flashes of light 
before the eyes, and sensations as if objects were distorted or seen 
through a fog. Temporary loss of vision sometimes occurs, and appears 
to be dependent upon ursemic poisoning of the central nervous system. 
The retina undergoes fatty degeneration and sclerosis — changes which 
are not pathognomonic of interstitial inflammation of the kidneys, since 
they are also observed in certain cases of acute and chronic paren- 
chymatous nephritis, and in connection with amyloid degeneration of 
the kidneys, as well as in other diseases. Even in chronic interstitial 
nephritis it only occurs in about seven per cent, of the cases. Its ex- 
istence is, however, an exceedingly valuable symptom which should 
direct attention to the kidneys, even though albumin be absent from 
the urine. 

Ophthalmoscopic examination reveals chronic retinitis ; the retina 
exhibits yellow spots, especially in the vicinity of the macula lutea and 
of the optic papilla ; the larger patches are dependent upon fatty de- 
generation in the layers of the retina, while the smaller, especially those 
in the vicinity of the macula lutea, are caused by sclerotic changes in 
the nerve fibres. In many cases the optic papilla presents the appear- 
ances of a choked disk which precisely resembles the choked disk that 
exists in cases of cerebral tumor or other diseases. The papilla is 
prominent, swollen, and red ; the retinal veins are dilated and tortuous, 
while the retinal arteries are reduced in size. In certain cases hemor- 
rhagic effusions are visible in the vicinity of the larger retinal vessels ; 
and by their absorption they originate white patches which must not be 
confounded with the sclerotic or fatty portions of the retina. The 
origin of these patches is associated with the alteration which the con- 
stitution of the blood has undergone, by which the retinal vessels lose 
the power of retaining their contents. (Edema and proliferation of the 



714 DISEASES OF GENITO-URINARY ORGANS. 

connective tissue, involving the sheath and trunk of the optic nerve, are 
sufficient to explain the existence of choked disk. 

During the course of chronic interstitial nephritis the other organs of 
the body exhibit evidence of disorder ; the skin becomes very pale, 
thin, and dry, and perspiration is greatly reduced ; in certain cases in- 
tolerable itching, or obstinate eczema may occur; the muscular system 
becomes enfeebled ; the appetite fails, though thirst is increased ; sleep 
is disturbed by the frequent necessity for the passage of urine ; eructa- 
tion or vomiting are not uncommon, especially when the phenomena of 
uraemia are developed; the bowels become constipated, though, in con- 
sequence of uraemia, severe diarrhoea or hemorrhage from the intestines 
may be developed ; the 'pulmonary organs exhibit an excessive tendency 
to inflammatory diseases ; sexual desire disappears. 

Chronic interstitial nephritis may continue for many years. Death 
from urwmia is more common than in any other form of Bright's 
disease. Inflammations of the serous membranes, to which the renal 
disease creates a predisposition, are frequently fatal, and cerebral hemor- 
rhage is not an uncommon event. Recovery rarely occurs. 

Diagnosis. From other forms of renal inflammation, interstitial 
nephritis may be differentiated by the copious discharge of urine with a 
low specific gravity, scanty sediment, very little albumin, and by the 
rare occurrence of haematuria or oedema. It is often difficult to distin- 
guish this form of nephritis from amyloid degeneration of the kidneys, 
unless evidences of amyloid degeneration in other organs are also 
present. 

Prognosis and Treatment. The prognosis is always unfavorable. 
The treatment should be continued in accordance with the rules laid 
down for the treatment of acute and chronic parenchymatous nephritis. 
If gout, syphilis, malarial cachexia, or chronic suppuration exist in con- 
nection with the renal disease, they require their own appropriate treat- 
ment. Iodide of potassium is frequently administered with the hope of 
cure, but very little advantage beyond its diuretic influence can be ex- 
pected. 

Uraemia. 

Etiology. TJrazmia signifies that association of symptoms which 
may follow every considerable interference with the excretion of the 
urinary constituents. In cases which are accompanied by a copious 
discharge of urine, it is probable that the urinary constituents have 
been for a long time previously retained in the tissues, and that the ex- 
cess of urine and the phenomena of uraemia are alike dependent upon 
their sudden and excessive liberation. 

TJrozmia occurs most frequently during the course of Bright's disease, 
especially when that assumes the form of chronic interstitial nephritis. 
It is less common in cases of acute nephritis, and is most rarely observed 
in chronic parenchymatous nephritis. It is more frequently developed 
after scarlet fever than after diphtheria. It is a very common compli- 
cation of cholera and pregnancy. It also occurs in connection with 
diseases which obstruct the urinary passages, especially when the urine 
undergoes decomposition in the bladder, and the ammoniacal product is 



DISEASES OF THE RENAL PARENCHYMA. 715 

reabsorbed. Strictures and tumors which occlude the ureters or other 
urinary passages may thus give rise to uraemia. It is therefore not an 
uncommon incident in the course of infective diseases, or in paralytic 
conditions of the bladder which are dependent upon spinal diseases. 

The theory of the dependence of uraemia upon the mechanical causes, 
such as compression of the capillaries and veins, by which cerebral 
oedema and anaemia are produced, is now generally abandoned. For a 
considerable time uraemia has been ascribed to the retention and decom- 
position of urea in the blood and tissues, where ammonia is supposed to 
be set free, and to excite uraemic symptoms. This theory is based 
upon the well-known poisonous effects of carbonate of ammonia, and 
upon the ammoniacal smell which is often perceived in the breath of 
uraemic patients. By certain authors the hypothesis was maintained 
that urea underwent excretion through the gastro-intestinal mucous 
membrane, and was there decomposed, liberating ammonia which was 
then reabsorbed, with consequent symptoms of ammoniacal poisoning. 
At the present time it is believed that not only the reabsorption of 
liberated ammonia, but also the retention of other urinary constituents, 
(kreatinin, ptomaines, leukoma'ines, etc.), give occasion for the develop- 
ment of uraemic symptoms. It has also been suggested that uraemia is 
developed not only by reason of the absorption of the ammoniacal prod- 
ucts of urinary decomposition in the diseased bladder, but that it is 
also dependent upon the coincident absorption of bacteria and their 
products which flourish in great quantities within the inflamed organ. 
Relapses are frequent. The disorder frequently develops suddenly, or 
it may be preceded by various nervous symptoms, such as headache or 
dizziness. So common is this connection that all cases of frequent head- 
ache should awaken a suspicion of renal disease. Trigeminal neuralgia 
is frequently occasioned by uraemia; sometimes other forms of neuralgia 
are also dependent upon the same cause. Anaesthesia, paraesthesia, 
and muscular spasms or epileptiform convulsions frequently occur as a 
consequence of uraemia. Occasionally, paralytic affections of a tran- 
sient character are observed. Aphasia and muscular tremor have been 
noticed. Frequently, consciousness is lost ; the patient appears somno- 
lent or comatose, lying in an unconscious condition with irregular respira- 
tion, and involuntary evacuation of urine and feces ; sometimes conscious- 
ness disappears only during the occurrence of epileptiform convulsions ; 
sometimes delirium and maniacal symptoms appear, and other symptoms 
of mental derangement have been occasionally observed. In certain 
cases total blindness may suddenly occur, may persist for several days, 
and then as completely disappear ; the cause of this phenomenon is not 
dependent upon any visible changes in the ocular structures ; it is prob- 
ably associated with functional changes in the cerebral centres. The 
pupils of the eyes are frequently contracted. The sense of hearing is 
also involved, and voices, bells, music, and various other sounds become 
audible ; a certain amount of deafness is not uncommon. Hemorrhages 
from the mucous surfaces of the body, vomiting and dysenteric diarrhoea 
often occur. The oedematous condition of the respiratory mucous mem- 
brane sometimes originates obstinate hoarseness or the occurrence of 
asthmatic paroxysms. Sometimes oedema of the lungs, or of the glottis, 



716 DISEASES OF GEXITO-URIXARY ORGANS. 

or inflammatory conditions of the pulmonary organs are developed. 
The serous -membranes of the body, especially the pleura?, sometimes 
become inflamed. 

In connection with uraemia the constituents of the urine are generally 
reduced in amount. Sometimes the termination of the uremic parox- 
ysm is accompanied by an unusually abundant discharge of renal casts, 
as if the urinary tubules had been suddenly relieved from obstruction. 
In certain instances the skin affords vicarious relief, and urea is depos- 
ited like frost-work upon the hair, and upon the surface of the body. 
Xot unfrequently the cutaneous nerves are greatly irritated, and there is 
complaint of insufferable itching. 

The course of uraemia manifests a marked tendency to reduction of 
the bodily temperature, though occasionally its increase has been known. 
The pulse becomes small and weak, and is frequently retarded. 

Uraemia is often preceded by minor forms of functional derangement. 
and it sometimes is developed suddenly in persons of apparently sound 
health ; in such cases a sudden convulsion, or an apoplectic attack, may 
be the first indication of any departure from the normal condition ; in 
other cases, it appears during the course of chronic renal diseases, after 
exposure to some cause by which the excretion of the urinary constitu- 
ents has been impeded. Sometimes it follows copious perspiration, or 
the rapid disappearance of dropsical symptoms ; in such cases anemic 
poisoning is due to the rapid return to the blood of excrementitious 
substances which had been harmlessly stored up in the tissues or in the 
dropsical transudation. 

Diagnosis. For the recognition of uraemia it is necessary to study 
its causes and to investigate the condition of the urine, in order to dif- 
ferentiate the disorder from the numerous cerebral, nervous, and mis- 
cellaneous diseases which are attended by pain, delirium, convulsions. 
and coma. 

Prognosis and Treatment. The prognosis is always serious. Pro- 
phylactic treatment is of the greatest importance. All patients who 
suffer with renal disease should be cautioned against the consequences 
of reduction in the amount and quality of the urine. 

The outbreak of ura?mic symptoms must be met by the administra- 
tion of remedies which promote the discharge of urine and neutralize 
the ammoniacal products that result from the decomposition of urea. 
For this purpose large quantities of strong lemonade should be admin- 
istered, and salicylic acid, benzoic acid, and other drugs which favor 
the elimination of urea must be prescribed. If the pulse indicates car- 
diac debility, a tablespoonful of the infusion of digitalis with a scruple 
of the citrate of potassium should be given every two hours : if this be 
insufficient to support the failing heart, half a drachm of a 10 per cent. 
solutioo of camphor in almond oil may be given hypodermically, three 
times a day. Ether, musk, and capsicum are also useful. Active 
diuretics accomplish little, since the kidneys are usually unable to re- 
spond to their action. It is better to arouse the vicarious action of the 
-kin and of the alimentary canal than to over-stimulate the renal appa- 
ratus. The compound infusion of senna with sulphate of sodium, or 
sulphate of magnesium, may be given in sufficient quantity to produce 



DISEASES OF THE RENAL PARENCHYMA. 717 

five or six copious watery stools each day. Colocynth sometimes pro- 
duces a similar good result. Diaphoretics should be employed with a 
certain degree of caution, since uraemia sometimes follows excessive per- 
spiration. Pilocarpine produces an excellent result if it does not act 
unfavorably upon the heart. Hot air baths are always beneficial ; hot 
water baths, followed by continued sweating under blankets in bed, are 
of great service, though at first it may be difficult to excite perspiration 
by these methods ; after their repetition, sweat flows more easily. 

The occurrence of epileptiform convulsions requires the administra- 
tion of chloroform ; chloral hydrate, in doses of 40 grains, also affords 
great relief. For puerperal eclampsia and cases of uraemia attended 
by a full and bounding pulse, venesection is strongly recommended. 
Uraemic asthma is promptly relieved by the hypodermic injection of 
morphine. 

Renal Abscess — Nephritis Suppurativa. 

Etiology. Suppurative inflammation of the kidneys is dependent 
upon their invasion by the various forms of bacteria that excite inflam- 
mation. These microorganisms find access to the kidneys through the 
bloodvessels or through the urinary passages. In this way ulcerative 
endocarditis may be followed by the passage of cocci from the heart to the 
kidneys. Puerperal inflammation and other septic, pyaemic, or infective 
processes may, in like manner, lead to suppuration and to the forma- 
tion of abscesses in the kidneys. In another class of cases, the inflam- 
matory process originates in the urethra, or in the bladder, or in the 
ureters, or in the pelves of the kidneys, and the renal tissue becomes 
infected by the ascent of microorganisms from below, either directly 
through the urinary passages, or indirectly through the blood and 
lymph vessels. 

Abscesses and other suppurative processes in the vicinity of the 
kidneys, sometimes, produce renal inflammation by extension of the 
primary disease ; but in certain cases it is impossible to distinguish the 
original process from the resulting renal inflammation. 

Pathological Anatomy. In many instances the size of the 
kidney remains unchanged ; its capsule at various points is adherent to 
the subjacent parenchyma ; the cortical portion is occupied by numer- 
ous minute gray points that are surrounded by a hyperaemic zone ; 
in the medullary portion similar changes appear in the form of striae 
which lie parallel with the tubular structures. Microscopical exami- 
nation exhibits numerous embolic obstructions in the bloodvessels ; 
the emboli consist chiefly of microorganisms that occupy the glomeruli 
and the intertubular capillaries ; around these are numerous round 
cells that accumulate and become associated with pus corpuscles ; the 
tubular epithelium swells and undergoes coagulative necrosis ; the 
tubules themselves are frequently occluded by clusters of micrococci ; 
in this way minute miliary abscesses are formed which may become 
confluent, thus producing larger depots of pus that may finally involve 
the entire kidney. 

Renal abscesses sometimes present considerable magnitude. In cer- 
tain cases rupture takes place into the pelvis of the kidney, and pus 



718 DISEASES OF GEXITO-URIXARY ORGANS. 

escapes through the ureter into the bladder ; in other cases the abscess 
may rupture into the peritoneal cavity, or into the alimentary canal, or 
behind the peritoneal sac, or into the thorax. Occasionally an external 
discharge through the abdominal wall takes place ; sometimes its 
purulent contents undergo caseation and calcification, and the kidney 
becomes deformed by the contraction of cicatricial tissue. 

Symptoms and Diagnosis. The recognition of suppurative ne- 
phritis is often impossible. Even the occurrence of albuminuria may 
frequently be explained by the infective diseases that underlie the 
suppurative process. When dependent upon injuries, there is com- 
plaint of pain in the loins, and the cremaster muscle is often spasmodi- 
cally contracted ; the patient is compelled to lie in the position that is 
accompanied by the least pain ; feverish symptoms frequently occur ; 
diuresis and hcematuria are not uncommon; in many instances, espe- 
cially after injuries, the symptoms of purulent nephritis are so inti- 
mately associated with those which are dependent upon the injury 
that they escape separate recognition. The occurrence of & fluctuating 
renal tumor is not an unfrequent event ; but it may also be caused by 
echinococci, or by some neoplastic growth. The swelling may be dif- 
ferentiated from tumors of the liver or spleen by its non-participation 
in the movements of respiration. Pus in the urine, though frequently 
due to renal abscess, may also proceed from suppuration of the renal 
pelvis or from the urinary passages. The presence of renal casts favors 
the hypothesis of renal suppuration, though they afford no certain 
indication. The presence of renal debris in the urine is a valuable 
indication, but it is a very rare event. Sometimes the rupture of a 
renal abscess in other directions first affords the indications for diag- 
nosis. 

The duration of the disease is sometimes very considerable. Death 
results from exhaustion, or from septic or uraemic conditions, or from 
peritonitis. 

Prognosis and Treatment. The prognosis is always very grave, 
and the treatment must be conducted in accordance with the rules of 
surgery. 

Amyloid Kidney — Ren Amyloideus. 

Etiology. Amyloid degeneration of the kidneys is dependent upon 
the same causes that produce similar degeneration in other organs. The 
disease occurs more frequently among males than among females. 

Pathological Anatomy. — Amyloid degeneration seldom occurs as 
an uncomplicated renal disease. It is generally associated with chronic 
parenchymatous inflammation, or with chronic interstitial nephritis. 
In its early stage it may be recognized by the aid of the microscope, 
but at an advanced period the degenerated tissue may become visible to 
the naked eye and can be easily demonstrated by its reaction with 
iodine. 

The affected glomeruli appear like gray, translucent granules which 
exhibit a mahogany-brown color on treatment with iodine. The kidney 
appears enlarged and increased in weight. The capsule may be easily 
stripped off ; its surface is smooth and pale, and the stellate vessels are 



DISEASES OF THE RENAL PARENCHYMA. 719 

injected; on incision the surface appears pale and waxy, and the 
density of the organ is increased. The breadth of the cortical portion 
is considerably increased, while the medullary portion exhibits little 
change in color or volume. 

Microscopical examination shows changes in the glomeruli ; they 
appear enlarged, thickened, and more homogeneous in structure than 
usual. The epithelial cells and their nuclei disappear in proportion to 
the extent of the degenerative process. The afferent and efferent ves- 
sels are next invaded ; at a later period the interlobular capillaries, 
and, finally, the medullary capillaries undergo degeneration ; the urin- 
iferous tubules are also invaded, and their epithelial cells participate in 
the general process. 

Along with the degenerative changes above described, inflammatory 
processes of an interstitial or parenchymatous type are usually asso- 
ciated ; the liver, the spleen, the intestine, and many other organs of 
the body are almost always simultaneously invaded by the amyloid pro- 
cess. 

Symptoms. The association of amyloid degeneration with inflam- 
matory forms of renal disease renders it impossible, in many cases, to 
distinguish between the symptoms of the one or the other form of renal 
disorder. In certain cases albuminuria may be absent, though the kid- 
neys have undergone extensive degeneration. Dropsy is not always 
present, consequently the existence of the disease can be inferred, 
sometimes, only from the history and cachectic condition of the patient. 

But, as a general rule, the urine is considerably diminished in quan- 
tity ; it is pale, acid, and of a low specific gravity, varying between 
1010 and 1015. In the scanty sediment may be found slender hyaline 
casts to which are frequently adherent oil globules, round cells, or 
tubular epithelium which has sometimes undergone fatty degeneration. 
In certain cases waxy casts that exhibit the characteristic reaction with 
iodine, may be observed. Red corpuscles are sometimes present. 
Albumin appears in considerable quantity. Of the other urinary 
constituents, phosphoric acid alone is diminished. Indican is present 
in considerable amount. 

Dropsy is a very common occurrence. The shin exhibits excessive 
pallor ; the temperature and the pulse remain without change. Diseases 
of the respiratory apparatus are exceedingly common, and the alimen- 
tary canal is often the seat of ulceration and of profuse diarrhoea. The 
retina and the circulatory apparatus are sometimes involved. 

The duration of the disease is exceedingly variable, and is depend- 
ent upon its underlying causes. Death almost always is the result, 
though recovery has been occasionally reported. Death is usually 
caused by uraemia or by inflammation of the serous membranes or of 
the lungs. In the majority of cases life is terminated by exhaustion. 
In many cases the concomitant forms of Bright's disease furnish the 
predominant symptoms and determine the mode of death. 

Diagnosis. The diagnosis of amyloid degeneration is imposssible 
in the absence of albuminuria. In every event, it is largely dependent 
upon the recognition of amyloid degeneration in the liver and spleen. 
From acute and chronic parenchymatous nephritis it may be differen- 



7 I ' diseases : : - z :■■ : r : - v ?. : >~ _-. ?. t : ■ ?. <:- a : 

tiate 3 the ::ce of hiematuria and by the low specif _ 

seiiment of the urine. Chronic interstitial nephritic is charac- 
terize ~ t'_ e greater amount of ur " _ 

*mall quantity of albumin, by the pies f cardiac hypertrophy 

and retinal disease, and by the -ence of drops 

Pe: 5K : : I z r :z: : The prognosis is always unfavorable, 
though recovery is : leasionaL- witnessed _ \ent must be 

addressed to the causes thai we roduced amyloid defeneration. 



■ c ■ 



Fa::y Kidney 

7 - nUltraticr vf tkt kidney*:- issoei with an abundance of 

the food, and with die existence of obesi iy. Fatty degeneration 

of the kidneys frequently results : _ nflammation. especially 

the tonic pare i lehyi nal yas form >f Bright a lisease. nd from other 

iiseases that rreiisr. :se :■: : iezene: ".:::r.. I: - _7-._tS ::-L1:-ws 

me mfmmtim :: :;m m ; . :: misimm^; *~it_ tiistmrus. irsemi. 
intim-iny. mrtmmm. mm tie mine mi mms 

Embolic Infarct: n ::' the Kidneys 

E-. ' ': :::;■>-. ;s -.-.sv. m _ : m. .. t~ me msmm: i : l :m 
vessel with an embolic lerived from the heart. The left kicbm 
involved more frequently than : he right, because the left i e nal artery 
forms with the aorta a more leutc ingle titan the rigl - inaction of 

the trunk of the renal artery may be followed by complete necr: m 
the entire kidney; but in the majority of instances the smaller arterial 
imm ^imm me mgan me tim seats :: : firms 

infarcts exist, the white and the red fc Both present a conical. 

t _ -ike form, with the base of the cone directed toward the sur- 
face of the kidney. J cfs are characterized by an anaemic 
condition of the ris sa es. The epithelial cell ; i : miles are in a 
condition of coagulative neerosia lie periphery _ illy sur- 
rounded by a hemorrhagic rone Hcmorrhagie inf less 
frequently bsenred. The lark-purple, conical form, and 
are finally transformed int _ w cheese- like mass, i 
legenei tion and absorption are followed by contraction of the cicatri- 
cial tissue. - ben numerous infarctions have occurred. 
me immm meset.ts . tm mi mi smmm '.'me: mmmm t :.s if me 
renal circulation may also lead to the production of hemorrhagic 
infer 

Symptoms ] irse of renal embolis 

t tended by chara sterol tome In many cases, how- 

ever, licated by sudden pain and tenderness on pressure 

the loins, and by vomiting, chills, high fever, and haematuria accom- 
panied by albuminuria and casts in the urine. 

Pp J gnosis de\ mtheea 

of embolism, and upon the extent of sb i n. The treatment consists 
in the relief of pain by the administration of opiates, and in the 
employment jf si 

The clothing of newborn children is frequently stained by the de- 



DISEASES OF THE RENAL PARENCHYMA. 



721 



posit of a reddish powder, which consists chiefly of urates that have 
been precipitated within the uriniferous tubules. (Figs. 138, 139). 
The same canals in adult life are sometimes occupied by similar 



Fig. 138. 




Hedgehog crystals of urate of soda spontaneously deposited from the urine 
of a child. (Roberts.) 



Ftg. 139. 




Amorphous urate deposit. (Roberts.) 
Fig. 140. 




Crystallized phosphate of lime. Selected to show various forms. (Finlayso.v.) 

46 



crystalline forms, and by the carbonate, or phosphate, or oxalate of 
calcium. (Figs. 140, 141.) Poisoning with corrosive sublimate is 







Fig. 141. 





Q 


D 


> - 


\<9 


' 


"."© * 


. b ^ 


'■__- 


« 


6 


<# » 



Oxalate of lime crystals. Selected to show various forms. (Fixlaysok. 

sometimes followed by a deposit of calcium carbonate in the renal 
tubules. In certain cases the tubules are obstructed with bilirubin or 
hsematoidin. 

Cancer of the Kidney — Carcinoma Renum. 

Etiology. Renal cancer may be either primary or secondary. As 
a secondary disease it results from primary cancerous diseases in other 
organs of the body. As a primary disease it generally exists without 
any apparent cause. Sometimes it is preceded by injuries or by cal- 
culi in the kidneys. It is observed in certain cases as a congenital 
disease. It is more frequent among men than amoog women, and is 
generally encountered at the extremes of life. Whether heredity 
exerts any influence upon its recurrence is unknown. 

Pathological Axatomt. Secondary cancer commonly involves 
both kidneys, but the primary disease usually attacks only one. and 
that, more frequently, the right kidney. Secondary cancer generally 
occurs in the form of circumscribed masses, while primary cancer in- 
vades the entire kidney. All varieties of the disease may be encountered. 

Renal cancers develop first in the epithelial structures of the organ. 
The resulting tumors may reach great size, occupying nearly the whole 
of the abdomen. The consistence of the tumor depends upon the na- 
ture of its structure. Where only one kidney is involved, the other is 
frequently hypertrophied. In many instances the liver, spleen, and other 
abdominal organs suffer great displacement. In certain cases the duode- 
num is constricted by the enlarged right kidney, and dilatation of the 
stomach is thus produced. Sometimes the ureters become obstructed 
with cancerous masses, leading to the development of hydronephrosis, 
or to the occurrence of hematuria. In other cases the large abdomi- 
nal veins are penetrated by the malignant growth. The neighboring 
Ivmph glands are generally involved by the disease, and by their pres- 
sure many nervous disturbances and vascular obstructions are produced. 
Peritonitis is not an uncommon cause of death in these cases. 



DISEASES OF THE EENAL PARENCHYMA. 



723 



Fig. 142. 



Symptoms. Renal cancer often remains unrecognized during life, 
especially when the primary disease is located elsewhere and masks the 
symptoms that arise in the kidneys. Sometimes the development of 
cachexia and progressive emaciation are the principal symptoms. In 
other cases, severe forms of neuralgia in the lower half of the body 
and limbs are the most conspicuous phenomena ; and, again, the first 
symptom may be afforded by a violent attack of hcematuria. 

The most certain indications of renal cancer consist in the develop- 
ment of a renal tumor and of hcematuria. (Fig. 142). A very charac- 
teristic symptom is afforded by the 
almost universal presence of the colon 
between the anterior surface of the 
tumor and the abdominal wall. Some- 
times this can only be observed when 
the colon is filled with air. That the 
tumor is not connected with either the 
liver or the spleen is demonstrated by 
its non-participation in the movements 
of respiration. It is usually nodu- 
lated, sensitive, and resistant to pres- 
sure, though sometimes fluctuation can 
be distinguished at certain points upon 
its surface. Puncture of the tumor 
under such circumstances yields a 
dark and bloody liquid which contains 
urea and uric acid. Pulsation, which 
must be carefully distinguished from 
that of an aneurism, is sometimes per- 
ceptible. 

ITce?naturia, though a frequent, is 
not a universal symptom of renal 
cancer. The urine contains blood in 
variable quantities, and sometimes 
clotted casts of the ureters are visible. They are often voided with 
considerable pain and interference with the discharge of urine. In cer- 
tain cases, detached fragments of the cancerous growth obstruct the 
urinary passages, and if they be voided with urine their specific charac- 
ter may be recognized by the aid of the microscope. In the absence of 
hematuria the urine presents nothing remarkable. Albumin is only 
present when the kidneys are themselves inflamed or undergoing amy- 
loid degeneration. 

Among the less characteristic symptoms are pain in the loins and in the 
course of the nerves which originate from the lower part of the spinal 
cord. Progressive emaciation and cachexia are developed. Insomnia 
is not uncommon, and disturbances of the alimentary canal are fre- 
quently observed. 

The average duration of the disease is about one year ; death some- 
times occurs suddenly as the consequence of hemorrhage. In other 
cases it results from progressive wasting, dropsy, diarrhoea, peritonitis, 
or ur?emia. 




Renal cancer. (Rush Medical 
College Clinic.) 



724 diseases 07 Gzy::o-';p,iXAEY organs. 

Diagnosis. Without the recognition of a tumor the diagnosis of 
renal cancel must necessarily be very obscure, an I iften after the dis- 
covery :f a tumor it is not always easy to distinguish it from tumors 
of the liver, spleen, stomach, pancreas, intestines, mesentery, abdominal 
glands, ovarian cysts, aneurisms, and psoas abscesses. From t 
the liver and spleen, a renal tumor may generally be differentiated by 
the absence of movement in harmony with the respiratory exam 
of the diaphragm. Gastric and intestinal tumors may T - 
when gastro-intestinal symptoms are present, and when the distention 
of the stomach and intestines with air causes displacement of the 
tumor. Fecal tumors may be suspected when their discovery has been 
preceded by a long-continued sonstipaiion. Ovarx vi P™g 

from the pelvic region and lie close to the abdominal wall, while 
tumors are generally separated from it by the colon. Psoas jhscess 
is characterized by a greater amount of pain and by Bonstant flexion 
and abduction :: the thigh. Aneurismal tumors may be recognized 
by their peculiar pulsation and by the retardation of the crural puke. 

Re ' mama cannot be differentiated luring life from r- tdt - 

. and it is very difficult to distinguish it from renal cysts, echino- 

::;::. or abscesses. Renal tuberculosis may be distinguished by the 

reserice of tubercle bacilli in the urinary sediment. The concurrence 

of a renal tumor and hematuria affords strong evidence in favor of 

cancerous disease. 

Prognosis a>~i> Treatment. Tke prognosis is bad Medical £r t- 
- must be purely symptomatic. For the results of surgical 
interference the student is referred to the text-be >oks m so 

Sarcoma, adenoma, fibroma, carcinoma, lymphangioma, myxoma, 
glioma, and lipoma, have aO been described among tumors involv- 
ing the kidneys. Thr Bchinococens parasite may develop in the kid- 
Qeya and may produce tumors of gi ?ry difficult to 

distinguish from other renal tumors. 

Renal Cysts — Hydrops Renum Cysticus. 

Renal cysts may be either congenital or acquired. He 

are often very numerous and develop to such a size that delivery 

a m\ sail le without embryotomy. The contents of the cyst are 

a clear, tra: is liquid which contains albumin, cholesterine. 

sphates. Urea is absent. Other deformi- 
iependent upon imperfect development are not unfrequently 
tti sometimes represent evelopment of 

rudimentary congenita systa ; in other instances they are the result of 
injur:— ►hich the uriniferous tubules 1 land 

consequently dilated. Not unfrequently the occurrence of urinary 
calculi is associated with the formation of renal cysts through obstruc- 
tion of the minute pass _ - :hin the kidneys. Tie dimensions of a 
ire sometimes very great - that the kidney may be converted 
_ -everal poc k By the confluence of a number 
of cysts a many-chambered cavity mav be formed in which distinct 



DISEASES OF THE RENAL PARENCHYMA. 725 

septa are visible. The contents are usually thin and watery, but occa- 
sionally they exhibit a colloid character, or may be tinged with blood. 
The microscope indicates the presence of epithelial and round cells, 
red blood-corpuscles, cholesterine tablets, triple phosphates, and various 
forms of detritus. Urea and uric acid are generally absent, while 
leucin and tyrosin are often present. Medical treatment affords no 
permanent relief, and surgical measures are almost equally fruitless. 

Movable Kidney — Ren Mobilis. 

Etiology. In about eighty-six per cent, of the cases of movable 
kidney the right kidney is involved. Both organs are occasionally 
displaced. In eighty or ninety per cent, of the cases the sufferers 
were females. The disorder is generally originated between the 
twenty-fifth and fortieth years of life. It is sometimes caused by 
injuries or falls, or by excessive muscular exertion ; it may result in 
the course of violent coughing, straining, or parturition. Less clearly 
apparent is the connection between wandering kidney and various ner- 
vous disturbances and diseases which have been assigned as causes of 
the difficulty. In certain cases it results from increase in the size and 
weight of the kidney, or from enfeebled and emaciated conditions by 
which the natural supports of the organ are reduced in quantity and 
efficiency. 

Symptoms. A movable condition of the kidney frequently escapes no- 
tice, or is first suddenly observed in connection with some unusual move- 
ment or position of the body. The degree of mobility presents great 
variations ; sometimes the kidney may fall as low as the pelvis, where 
it presents a tumor of renal form, tender on pressure, and connected 
with the pulsating renal artery. Sometimes the empty socket from 
which the kidney has escaped yields a tympanitic sound on percussion. 
In certain cases polyuria is observed so long as the kidney remains dis- 
located. Not unfrequently paroxysms of severe pain are experienced. 
Vomiting, shivering, cold perspiration, and reduction in the amount of 
urine, are observed. Sometimes there is blood or pus in the urine. 
These paroxysms are supposed to depend upon incarceration of the 
kidney, or upon torsion of its pedicle. In certain instances the par- 
oxysms are probably dependent upon local inflammation, or upon ob- 
struction in the course of the ureter. 

Various hysterical disturbances which are liable to aggravation 
during the menstrual period, are frequently observed. Sometimes 
jaundice is produced by pressure upon the common bile-duct ; or dila- 
tation of the stomach may originate from compression of the duodenum. 
Occasionally paraplegic symptoms are produced by pressure upon the 
nerves that lead to the lower extremities. In the same way oedema 
may arise from venous compression. 

Diagnosis and Treatment. It is not always easy to distinguish 
a wandering kidney from other abdominal tumors, unless it can be 
recognized by its form and by the pulsation of its artery. If any 
remediable cause for displacement of the kidney exists, treatment 
should be directed to that condition. Improvement of the general 



726 DISEASES OF GE XITO-U RIX A R Y ORGANS. 

health sometimes exerts a favorable influence, and paroxysms of pain 
require the ordinary methods for the relief of suffering. Bandages and 
belts afford comparatively little benefit, so that it becomes necessary in 
serious cases to have recourse to surgical measures. Of these, the 
favorite methods are nephrectomy and nephrorrhaphy ; of these, the 
last is the least dangerous, but its results are also the least satisfactory. 

Horseshoe Kidney — Ren Unguiformis. 

In certain cases the two kidneys become more or less adherent or 
coalescent by their inferior extremities. Their pelves, ureters, and 
bloodvessels, in such cases, usually present notable departures from the 
ordinary type. The peculiarity can seldom be demonstrated during 
life, though sometimes in slender persons, a tumor lying across the 
aorta may be demonstrated in the posterior portion of the abdominal 
cavity. Occasionally, uremic symptoms, or thrombosis of the inferior 
vena cava, may be produced by its pressure. 

Absence of the kidney and the presence of superfluous kidneys 
have been described in certain rare instances, but these unusual inci- 
dents possess no clinical importance. 

Para-Nephritis. 

Etiology. Para-nephritis is an inflammation of the loose connec- 
tive tissue vrhich surrounds the kidney, behind the peritoneum where the 
renal pelvis is placed. Consequently, the disease is often excited by 
previous inflammation in that portion of the urinary passages. It is 
sometimes, however, excited by injuries, by exposure to cold, or by the 
propagation of inflammation from the kidneys or urinary passages into 
the para-nephritic connective tissue. It sometimes follows operations 
upon the pelvic organs or urethra. It may result from peritonitis, or 
from tubercular disease of the spinal column, or from inflammatory dis- 
eases involving any of the abdominal or thoracic organs. The infec- 
tive diseases may also operate as exciting causes of the inflammation : 
but sometimes no definite cause can be assigned for its existence. 

Para-nephritis occurs more than twice as often among men as among 
women ; it is usually encountered between the twentieth and sixtieth 
years of life, though it is sometimes observed among young children. 

Pathological Anatomy. Para-nephritis almost always occurs as 
a unilateral disease. Among males it is most frequently observed upon 
the left side, while among children and women, the right side is its 
favorite seat. 

The disease occurs either in the form of a diffuse, purulent infiltra- 
tion, or as a circumscribed abscess. Its contents frequently emit a 
fecal odor, like other abscesses in the neighborhood of the intestinal 
canal, even though no communication with the intestines may exist. 
Occasionally, gangrenous processes are set up ; sometimes the accumu- 
lation of pus is so great that the kidneys seem to float in the extensive 
cavity of the abscess. Re-absorption rarely takes place. The purulent 



DISEASES OF THE RENAL PARENCHYMA. 727 

effusion may become caseated ; and this transformation is accompanied 
by the development of cicatricial contractions which sometimes encroach 
seriously upon the kidneys, or upon the portal vein. In the majority 
of cases, however, pus finds its way through the loins to the surface, or 
it burrows into the thorax, or effects an entrance into the peritoneum or 
into the cavities of the abdominal and pelvic organs. 

Symptoms. Para-nephritis sometimes develops in a very insidious 
manner ; in other cases it is ushered in by the symptoms of high fever 
and severe pain in the loins. The principal symptoms of the disease 
are fever, pain, and the devopment of a tumor in the region of the kid- 
neys. Pressure over the seat of inflammation increases the sensation of 
pain ; sometimes the suffering presents an intermittent character like 
that of neuralgia. Occasionally it extends to the pelvis and thighs. 
As the disease progresses, swelling can be frequently discerned in the 
loins, especially when the patient stands erect. The skin becomes 
smooth, shining, hot, and red ; finally fluctuation may be distinguished. 

In the majority of cases the patient is compelled to lie in a position 
that will relax the tension of the inflamed parts. Fever is present, 
constipation is often produced by compression of the colon, and dyspnoea 
results from interference with the movements of the diaphragm. The 
urine ordinarily presents no particular alteration, though albuminuria 
is sometimes observed as a consequence of compression of the renal 
veins. 

Spontaneous resorption of the pus is not to be expected. The course 
of the disease may continue for three or four weeks, if proper surgical 
treatment is employed ; but, if left to itself, it may continue for many 
months. Spontaneous evacuation of pus may occur upon the external 
surface of the body, or a communication may be effected with the 
alimentary canal, or the renal passages. Perforation of the peritoneal 
cavity is the most dangerous sequel, though death frequently results 
from the penetration of pus into the other organs of the body. 

Amyloid degeneration is one of the complications that may follow 
para-nephritis. Sometimes dangerous hemorrhage follows the forma- 
tion of abscess. Miliary tuberculosis is sometimes observed as a com- 
plication of the disease. Even after apparent recovery, dangerous 
consequences may follow from the contraction of cicatricial tissue. 

Diagnosis. Para-nephritis may be mistaken for lumbago, in which, 
however, the pain is superficial, and fever and swelling are absent. 

It may be mistaken for a superficial abscess in the loins ; but here all 
the symptoms are characterized by a superficial and transitory character. 

It may be distinguished from empyema, which is discharged through 
the loins by the absence of any considerable tumefaction about the kid- 
ney, and by the presence of the characteristic thoracic symptoms. 

It may be distinguished from spinal tuberculosis by the absence of 
pain and deformity in the spinal region. 

It may be distinguished from diseases of the kidneys and of the 
renal pelvis by the presence of fever, pain, and swelling in the loins. 

It may be distinguished from inflammation of the ccecum and its 
neighborhood by the different location of the pain and swelling, and by 



728 DISEASES OF GEXITO-URIXARY ORGAXS. 

the absence of severe intestinal disturbances. The urine also contains 
a greater amount of indican. 

It may be distinguished from psoitis by the fact that the leg and 
thigh upon the affected side can be extended without pain, a movement 
that is impossible when the muscle is inflamed. 

It may be distinguished from hip-joint disease by the mobility of the 
limb, and by the absence of pain from the joint. 

From other abdominal tumors it must be differentiated by the appli- 
cation of the rules which have been laid down for the diagnosis of renal 
cancer. 

Prognosis ahb Treatment. The prognosis is comparatively favor- 
able in cases which admit of early recognition and efficient surgical 
treatment. Much depends upon the nature of the cause by which in- 
flammation was excited. The treatment rests entirely upon surgical 
principles. It consists chiefly in the repeated application of poultices, 
in the administration of narcotics for the relief of pain, and in free in- 
cision so soon as fluctuation can be detected. 



DISEASES OF THE SUPRA-RENAL CAPSULES. 

Addison's Disease — Morbus Addisonii. 

Etiology. Addison's disease, first described by Thomas Addison 
in the year 1855. is associated with various morbid changes in the 
supra-renal capsules. It usually occurs between the fifteenth and 
fortieth years of life, though occasionally it has been encountered at an 
earlier or later period. It is more common among men than among 
women, especially among the poor. It usually involves the supra-renal 
capsules alone, though it has been sometimes encountered after injuries 
in the loins, or after exposure to great anxiety and care. In certain 
cases the disease is associated with tuberculosis of the lungs, or of the 



spinal column, or of the uro-genital organs. It has been observed also 
in connection with inflammatory diseases of the gastro-intestinal tract, 
or in connection with cancerous disease, or wasting discharges that lead 
to amyloid degeneration. 

Symptoms. Addison s disease is generally preceded by vague 
symptoms of disorder in the digestive organs, profound depression of 
spirits, and progressive debility. There is loss of appetite, eructation, 
nausea, vomiting, pain, and distention in the region of the stomach : 
sometimes severe diarrhoea exists : emaciation and loss of strength 
make rapid progress : occasionally the region of the kidneys is sensitive 
to pressure, and rheumatic pains are experienced in the muscles and 
joints. In certain cases the above-mentioned symptoms complete the 
picture of the disease, but, usually, changes in the color of the skin are 
gradually developed. This especially involves those portions of the 
cutaneous surface that are exposed to the air. and those regions which 
naturally exhibit deep pigmentation, e. g., the nipples, the armpits, 
and the perineum. At first the skin exhibits a dirty-brown color, as if 



DISEASES OF THE SUPRA-KENAL CAPSULES. 729 

it were not quite clean. This discoloration develops in irregular patches 
that gradually coalesce. In many cases the skin becomes darkly pig- 
mented, like that of a mulatto or of an Indian. Old scars sometimes 
remain free from pigment, but in other cases it is more abundantly de- 
posited in their substance than elsewhere. In strong contrast with the 
other portions of the cutaneous surface remain the palms of the hands, 
the soles of the feet, the nails, the teeth, and the sclerotic coats of the 
eyes. In certain cases pigmented areas may be observed inside of the 
mouth, upon the inner surface of the cheeks, opposite the teeth. 

The pulse is generally rapid, small, and soft, and anaemic murmurs 
are audible over the heart and large bloodvessels. The blood exhibits 
evidences of impoverishment ; but the urine, though presenting great 
variations in its chemical constituents, furnishes no characteristic 
changes that throw any light upon the nature of the disease. 

Besides the progressive disorders of digestion and nutrition which 
have been already described, many nervous symptoms are frequently 
observed. In addition, painful conditions of the muscles and joints, 
and an inclination to faintness are often exhibited. Sometimes con- 
vulsions occur, and paralytic symptoms occasionally involve the 
extremities. Severe delirium and maniacal paroxysms have been 
described. 

The disease generally terminates in death in the course of a few 
months, yet in rare instances life has been prolonged for two or three 
years. Death occurs from exhaustion, or in connection with cerebral 
disturbances. 

Pathological Anatomy. Characteristic pathological changes are 
observed only in the supra-renal capsules. Cancerous disease and other 
forms of local degeneration are less commonly followed by the develop- 
ment of the pathognomonic symptoms. Their appearance during life 
without the occurrence of local changes in the capsules which can be 
demonstrated after death, forms a rare exception to the general rule. 

An attempt has been made to show that the symptoms of Addison's 
disease are less dependent upon pathological alterations in the supra- 
renal capsules than upon morbid changes in the sympathetic nervous 
system. The solar plexus has been incriminated as the principal seat 
of disorder ; but, though frequent observations have demonstrated the 
existence of various disorders of nutrition and degeneration in the 
ganglionic cells, nerve fibres, and bloodvessels within the solar plexus, 
the frequent absence of all such evidences of disease furnishes an argu- 
ment against this hypothesis. In like manner, the various pathological 
changes that have been noted in the spleen, liver, mesenteric glands, 
red marrow of the bones, spinal cord, and elsewhere, are merely occa- 
sional and accidental phenomena. 

So long as the functions of the supra-renal capsules remain unknown, 
it must be impossible to explain their connection with any form of 
disease. For this reason the pathology of Addison s disease is still 
in a most unsatisfactory condition. It is probable that the symptoms 
are dependent upon functional disturbances of the sympathetic nerve, 
by which discoloration of the skin and progressive debility are pro- 
duced. This unexplained functional disorder is usually dependent 



V". i :s s as z 5 :r :-i:~:t : -z z . : . "a- _ ._-.-., 

upon caseous degeneration of the supra-renal capsules : bat it may be 
associated with local disease of the sympathetic system itself; while in 

: ... '.'._■_.:- \ ;".-:: ::.— - :: :-rirs :: Zr : .:. - ~ : ' \zz\z. : l -.'. i:?- 
order. onassociated with any risible pathological changes. Beyond 

I : -". " . -i: ±?z ?.-.:.-:>:-:: lie .- - ; :•:":•: :. : .. 

son's disease may be easily distinguished from eyanosU by the met 

:li: :: nzz l= "._ :i a^t! :~ : :e~ . - ~ .-'_ :_t ~i_t. jf: 
mentation after the long-continued Mas of nitrate of tttrer m 

'.-.-. -:.:: :t '. '." :..- "_ :s:-:-rr : :_t : .— v -. - -. ;i : -:_t:._t ; 

.;:::■ ::::„:::• ...::::, ": :: . . • — - :_t t^t ; t ::'_ : 

'_:- >:•;:. L: ,:-:: :::::.: i :/:_:/*:,":' :: -'.-: ?:."'. £rr"j^rii:> ir: ii?es i 
discoloration of the skin that is Tery similar to that of Addison's 

f:~ " t -~tti:: . . ^ :- . £r:~ .\z.::".: _ . Z_t . • .- ~ ~« 

7zz±zi-Lzyz I-t :.t: :_t.:: _: ; : :-f ; v..e'.- ?-z:r:-:z:i:: : 



C HAPTBB III. 
z:-za-e- ;z zzz zz>~az ?zit:e a>~: :z :zz tzzzzz 






he way of 



. ■..:- . :• .-:..: :. : :if ::t:t: hit :e?i.: :: . _ 

v . ../ . : . :. : . \ . " " :: ::: — •-, . ?.* : 7 :in :rs :t 

!atrieial tissues, or any other cause that may interfere with the per- 

- :. : : ..- :. ine: .'.- • 7'. . ~ — .— : ^l.:Z :lt~ ire : .:: :ia^t 

Pathoi*-:-: :r. Hy<lrontphro*is is characterixed by great 

: : :. : :;.- ::.:.::. Z \ "i. .-. .:.; ::'.vr« .:. 1:^:775 ^;zir:.i_r: ::: 
lated ureter rivals the intestine in sire, and mar exhibit similar con- 



DISEASES OF RENAL PELVIS AND OF URETER. 731 

volutions. The renal pelvis is frequently transformed into a sac as 
large as the bladder. Sometimes no traces of renal tissue can be dis- 
covered ; but, in many instances, the kidney persists in the form of a 
thin, flattened, placenta-like mass upon one side of the sac, and, on 
microscopical examination, exhibits traces of the glomeruli and urinifer- 
ous tubules. This atrophy of the organ is gradually developed by 
retrograde pressure through the pelvis and infundibula. The papillae 
first disappear, then the medullary portion, and finally the cortical 
structures of the kidney yield and disappear. 

In many instances the external surface of the sac is adherent to the 
adjacent intestines. Its inner surface resembles a serous membrane. 
Its capacity becomes enormously developed, so that its contents have 
been known to reach fifteen gallons. The liquid is thin, pale, and 
transparent, though sometimes it exhibits a smoky color, by reason of 
hemorrhagic extravasation. Occasionally the fluid is consistent, like 
jelly. In rare instances it becomes purulent and undergoes inspissa- 
tion, caseation, and calcification. Microscopical examination reveals 
the presence of epithelial cells, round cells, colorless blood-corpuscles, 
fatty nuclei, and tablets of cholesterine, or fragments of renal tissue. 
In old cysts, urea and uric acid can no longer be detected. 

Symptoms. The most prominent symptom of hydronephrosis con- 
sists in the presence of & fluctuating tumor which cannot be referred to 
any other form of renal disease, and for which the probability of occlu- 
sion in the urinary passages exists. In severe cases the abdomen is 
greatly distended, and the colon can usually be discovered between the 
tumor and the abdominal wall. 

When only one kidney is involved, the other kidney may yield 
healthy urine, but when both kidneys suffer, urcemia and death may 
very speedily occur. Sometimes the tumor exhibits intermittent changes 
in its size which are conditioned by variations in the degree of urinary 
obstruction that exists. The liquid contents of the sac, in such cases, 
may be partly evacuated and then replaced by renewed accumulation. 

As the tumor increases there is complaint of difficult respiration, 
internal pressure, and distress, by reason of its encroachment upon the 
other organs of the body. Various symptoms of disturbance, such as 
fever, constipation of the bowels, difficulty in the passage of urine, and 
local pain, are frequently experienced. Sometimes hematuria occurs, 
and rupture of the sac is often followed by peritonitis. Suppuration 
excites a fever that tends to assume the hectic type, and is frequently 
followed by exhaustion and death. If the sac rupture into the other 
cavities or organs of the body, the characteristic disturbances of such 
invasion will be displayed. Sometimes the lower limbs become oedema- 
tous in consequence of the pressure upon the large veins. 

Diagnosis. It is often difficult to distinguish hydronephrosis from 
other renal tumors. The diagnosis must depend largely upon the 
demonstration of a tumor coincident with obstruction to the exit of urine. 
The passage of hydatids with the urine, or the presence of tubercle 
bacilli in the urinary sediment, or the existence of cachexia, would 
favor the diagnosis of echinococci, or renal tuberculosis, or cancer. The 
disease is not unfrequently confounded with ovarian tumors, or with 



"■:_ ::;Ia-Z5 :■? szmto-ubifabt obgahs. 

pregnancy, : even with ascites. Exploratory puncture for the purpose 
of diagnosis is attended with some risk of peritonitis, :. - the fluid 
trickles easily through such an opening into the peritoneal cavity. 

Prognosis and Treatment. The prognosis is very doubtful. 
The treatment must consist largely in the attempt to remove obstruc- 
tions from the urinary passages : or if this cannot be accomplished, re- 
course must be had to nephrotomy or to nephrectomy, though this 
operation is often rendered impossible by the existence of extensive 
adhesions. 

Pyelitis. 

Etiology. Inflammation, of the renal pelvis may be either primary 
or secondary, acute or chronic, catarrhal, purulent, or hemorrhagic. 
The catarrhal and purulent forms of the disease may originate ir. ex- 
posure to cold, or as a consequence of injuries, or as a result of irritation 
of the mucous membrane of the renal pel : .Iculi. by parasites 

(echinococci, strongylus gigas. tubercle bacilli, etc.). or by fragments of 
cancerous tissue. 

The most common cause of pyelitis is derived from obstruction to the 
exit of urine, especially when the urine has undergone decomposition 
and swarms with parasitic microorganisms that irritate the pelvic sur- 
: :. : e . 

Pyelitis also occurs in connection with diabetes me' as a con- 

sequence of the excessive use of acrid diuretics, cantharides, oil of 
turpentine, and various balsams. Sometimes it follows the course of 
infective diseases ; and it is often the result of inflammation thai 
, ■/',: .-':-. :1 "-: ' ■:.,. : : ."" n: .*:■*■(:■::<?■:.<. 

Pyelitis is more frequent in middle life than in youth : among males 
rather than among females, especially because of the greater prevalence 
of renal calculi among the male sex . 

Pathological Anatomy. Acute pyelitis is characterized by red- 
ness and swelling of the mucous membrane in the renal pelvis. The 
epithelial surface is exfoliated and covered with a thin, slimy fluid that 
sometimes contains pus corpuscles. This process of exfoliation in many 
noes progresses until ulceration and perforation of the pelvic wall 
take place 

Chroni exhibits a darker color of the mucous membrane, of 

which the surface is often deeply pigmented and covered by villous 
proliferations of the submucous tissue. A: various points ulceration is 
evident, and the pelvic wall is generally thickened. A deposit of 
urates and ammonio-magnesian phosphates is not uncommon upon its 
inner surface. The entire cavity is frequently dilated by the operation 
of causes similar to those by which hydronephrosis is produced, and the 
renal tissue may become in like manner atrophied. Xot unfrequently 
pyelitis and purulent nephritis are associated together, constituting 
pyelo-nep The whole sac may thus become distended with pus. 

producing what is termed pyo-nej 

It occasionally happens that, after an entire kidney and its pelvis 
have been thus disorganized, the purulent contents of the resultiri.- a 



DISEASES OF RENAL PELVIS AND OF URETER. 733 

may become caseated and undergo calcification, while the other kidney 
becomes hypertrophied by a compensatory increase of its function. 

Symptoms. Pyelitis sometimes remains unrecognized during life 
because of the overwhelming severity of the symptoms that are con- 
nected with its remote cause. Its characteristic symptoms are pain in 
the region of the kidney ; frequent and painful desire to pass urine, 
which is followed by the escape of only a few drops at a time, and at- 
tended by great suffering. The urine, which is otherwise normal, con- 
tains pus and mucus. Albumin, in uncomplicated cases, is present in 
amount corresponding with the quantity of pus. The total discharge 
of urine is considerably increased, so that many cases of polyuria may 
perhaps be referred to an unrecognized pyelitis. 

The urine is usually very copious and contains pus corpuscles ; it 
also contains epithelial cells from the renal pelvis, but they can be very 
easily confounded with similar epithelial cells from the deep layers of 

Fig. 143. 




Epithelial cells from the bladder, ureter, and pelvis of the kidney. (Roberts. 



the mucous membrane of the bladder. (Fig. 143). Red blood-corpus- 
cles are very rarely observed, except in cases where renal calculi exist. 

When pyelitis is complicated with hydronephrosis a renal tumor can 
generally be observed. If nephritis also occurs, the amount of albumin 
in the urine will exceed that which is due to the presence of pus, and 
casts will exist in the sediment. If renal calculi exist in the urinary 
passages, they will occasion hemorrhages of renal colic. Parasites 
may also indicate themselves by their presence in the urine ; and, if 
the disease is dependent upon obstruction to the exit of urine the symp- 
toms of chronic inflammation of the bladder will be developed. 

The duration of the disease depends upon its cause, and may be pro- 
longed for months or years. 

Paraplegia or paraparesis are sometimes observed as consequences of 



734 3ES OF SENITO-UBIRABY ORGANS. 

inflammation propagated from the urinary | sages to the ner 
system. 

Pyelitis may result in complete cure, or it may produce such exhaus- 
rmaciation. and collapse, that death shall result ae enee. 

sy. suppression of urine, and urcemia aometimee :r. Para- 

nephritis has been sen I : and in certain cases the purulent contents 
of the renal pelvis have found their way to the surface, or have rup- 
tured into the internal cavities and organs of the body. 

DlA 3N0SIS. It is often difficult to decide whether pus in the urine 

?eds from the kidneys, or from a para-nephritic at-:.-. : from 

the bladder, r from other portions of the urinary tract. The existence 

of a tumor in the region of the kidneys ren axis a probability. 

:ed by alkalinity of the urine. Prt - 
■- ' ftammaiion is indicated by painful swelling of the gland : and 
urethritis may be recognized by its well-known symptoms. 

Prognosis and Treatment. The prognosis is very unfavorable, 
though recovery may occur in certain cases. Every obstruction in the 
jf the free passage of urine should be removed, if possible. The pa- 
tient should remain in bed. and his diet should consist chiefly of liquid 
ri-ially milk and lime-water. The alkaline mineral waters may 
rjommended. Pain must be relieved by the hypodermic m 

ind atropine, and poultices may be applied to the region of 
the kidneys. If the discharge of mucus and -. tan- 

nic acid and opium may be administered. Sometimes acetate of lead 
may be emplc ith advantage, and the infusion of uva urs: is : 

lerable value. Sometimes benefit is obtained from small do- 
oil of turpentine or other balsamic preparations. Tincture of eanthar- 
ides. in twenty-five-drop doses, three times a day. has received favora- 
ble mention. Salol. in ten-grain doses every three hours. > dsc very 
beneficial. 

In severe and chronic cases surgical operation is often advisable 
for the relief : the patient. 

Renal Calculi — Nephrolithiasis. 

Etiology. Cal-uJ: \ts may be precipitated from the 

urine with the formation of calculi in any portion of the urinary pas- 
sages I: formed in the renal infundibula or pelvis they may be 
tran- :o the ureter, into the bladder, or into the urethra. They 

are usually formed in the renal pelvis, from which they may work their 
into the renal tissues, or in other directions. Thev occur, most fre- 
quently. in childhood or in old age. and are much more common among 
males than among females, especially among those who consume 
quantities of flesh, wine, and beer. Laborious people who live much 
in the open air. rarely suffer in this way. In certain localities a pre- 
disposition to the occurrence of calculi seems to exist, though upon 
what it depends is not clearly apparent. Sometimes it depends appar- 
ently upon hereditary influences : while certain persons manifest an 
individual pre 3] - tion which may result in the formation of calculi 
a _ ocation. I see Lave been known in which a f en _ ssea 



DISEASES OF RENAL PELVIS AND OF URETER. 735 

of wine would be followed by the production of a renal calculus. Occa- 
sionally, injuries affecting the region of the kidneys have been followed 
by the formation of calculi ; and diseases of the kidneys or of their pelves, 
especially if associated with stagnation of the urine, are specially lia- 
ble to be followed by calculous disease. It also occurs frequently 
in connection with gout and diabetes, and in the course of osteomalacia. 
In these maladies the retardation of oxidation and the consequent 
disturbance of nutrition are common factors in the production of 
uric acid and oxalic acid calculi. Phosphatic gravel exists as a 
consequence of inflammation in the bladder or renal pelvis, and its 
development occurs under the influence of microorganic activity. 
When the lining of the bladder is inflamed, an earthy deposit 
occurs upon its surface, or upon any foreign body that may be 
present. In this way a uric acid nucleus may become incrusted with 
phosphates. If the inflammation be arrested, and the urine again be 
restored to its former condition, a second layer of urates may be de- 
posited ; and thus a succession of different concentric layers may be 
discovered in the same calculus. 

Uric acid is not deposited in healthy urine. But, if the urine be in- 
ordinately concentrated by excessive perspiration or insufficient drink, 
or if the processes of oxidation be hindered in the tissues, so that an 
excess of acid phosphate appears in the urine, the uric acid is pre- 
cipitated, and calculi are formed. (Fig. 144.) 

Fig. 144 




Various forms of uric acid crystals. (Selected from Otto Funke's Physiological Atlas.) 



Pathological Anatomy. Calculi are generally found in only one 
renal pelvis, though occasionally both organs are affected. Calculous 
precipitates exist either in the form of a fine, granular or crystalline 
powder (renal sand), or as separate, massive concretions which may 
vary in size from that of a grain of wheat to a mass weighing two 
pounds. Renal sand consists chiefly of uric acid and its compounds. 

Renal calculi exhibit different forms ; they are usually oval or some- 



736 DISEASES OF GENITO-U RIN AR Y ORGANS. 

what irregular in shape, though sometimes they are furnished with 
numerous processes which remind one of the form of a caltrop, or of 
branching coral. Their density, color, and friability depend chiefly 
upon their chemical composition. Seven varieties of renal calculi are 
known. 

1. Calculi composed of uric acid. 

2. " " " oxalate of calcium. 

3. " " u phosphates. 

4. u " " carbonate of calcium. 

5. " " " cystin. 

6. u " " xanthin. 

7. " " " indigo. 

In certain cases compound calculi exist which are composed of alternate 
layers of a different chemical constitution. If a calculus be laid open, 
a nucleus at the centre may be discovered, around which the mineral 
matters were deposited. Sometimes parasites, or other foreign bodies, 
such as minute blood clots, have furnished the original nucleus. The 
deposit of mineral matter appears to take place not as a mere precipitate 
but as an infiltration of a delicate, albuminoid framework by which the 
nucleus is constituted. 

Stones composed of uric acid or of urates are the most common. 
They are very hard, smooth, and polished, or sometimes slightly gran- 
ular upon the surface. They are generally composed of alternate layers 
of darker and lighter color. Sometimes these layers consist of alternate 
films of uric acid and oxalate of calcium, and sometimes the external 
surface is covered with a thin layer of earthy phosphates. 

Oxalate of calcium calculi are exceedingly hard, and exhibit a warty 
surface, from which is derived the common appellation of mulberry 
calculi by which they are known. Their color is usually a dark brown, 
and they frequently consist of alternate layers of oxalate of calcium 
and uric acid. 

Phosphatic calculi consist usually of phosphate of calcium and am- 
monio-magnesian phosphate. Their color is gray, and their substance 
is somewhat friable. 

Carbonate of calcium calculi rarely occur in the human species, but 
are very common among cattle. They are small, gray or brown, earthy- 
looking concretions. 

Calculi composed of cystin are very rare. Their surface is some- 
times smooth, sometimes rough and crystalline. Their color is a dull 
white or amber-yellow. Occasionally they present a greenish or bluish 
color. 

Calculi composed of xanthin are also very rare. They are composed 
of layers of a yellowish or brownish color. 

Indigo calculus is another extremely rare formation which somewhat 
resembles in structure and appearance a fragment of indigo. 

Renal calculi almost always produce inflammation of the mucous 
membrane of the pelvis. Occasionally this results in ulceration, by 
which calculi may find their way into neighboring cavities or passages. 
The kidneys are also liable to inflammation from calcular irritation, by 
which interstitial proliferation may be excited, or abscesses may be 



DISEASES OF RENAL PELVIS AND OF URETER. 737 

formed, so that both the kidney and its pelvis may be converted into an 
immense cavity filled with pus and calculous masses. Not unfrequently 
Bright's disease is associated with the formation of calculi. 

If the process involves one kidney, the other may become greatly 
enlarged through compensatory hypertrophy ; and if prolonged suppura- 
tion exist, amyloid changes may be developed. 

If a calculus escapes from the pelvis and finds its way into the 
ureter, there is danger of the occlusion of that passage, and the conse- 
quent development of hydronephrosis. If a stone becomes impacted in 
the ureter, it may lead to ulceration and perforation of its walls. Other 
mucous inflammations may be excited along the course of the urinary 
tract by the passage of renal calculi. 

Symptoms. Renal calculi frequently occasion no symptoms during 
life, but sometimes they are unexpectedly voided with the urine without 
having produced any previous pain or inconvenience. 

In many cases, however, gastric disorders exist, such as pain, retch- 
ing, and vomiting, which persist at intervals so long as the calculi 
remain in the renal passages. More frequently, however, the symp- 
toms of vesical catarrh or of pyelitis conceal the presence of a stone. 
Sometimes the only symptom that is presented is a repeated hcemat- 
uria ; this symptom is especially valuable when associated with severe 
pain in the region of the kidneys or along the course of the ureter. It 
is very rarely the case that stones of a size or number sufficient to pro- 
duce a recognizable tumor can be found, but not unfrequently hydro- 
nephrosis or renal abscess may have their origin in calcular obstruction. 

One of the most characteristic symptoms of renal calculi is furnished 
by the occurrence of renal colic, though this painful affection may be 
produced by the passage of hydatids, or blood clots, or cancerous masses, 
or other obstructions through the ureters. An attack of colic gener- 
ally originates suddenly, either after some active exertion or occasion- 
ally during sleep. It is characterized by frightful pain that is utterly 
intolerable. It is located in the region of the kidney, or along the 
course of the ureter as it descends into the pelvis, but it may irra- 
diate throughout a wider territory. Usually the cremaster muscle is 
spasmodically contracted and the testicle is drawn up to the inguinal 
ring. The pain recurs in paroxysms which last for several minutes, 
and then give place to more or less complete relief. Usually the 
paroxysm terminates abruptly, either in consequence of the return of 
the stone into the pelvis or by reason of its entrance into the bladder. 
Such attacks of colic are frequently accompanied by chills, fever, 
vomiting, fainting, loss of consciousness, and sometimes by convulsions. 
The patient bends himself double or throws himself into all manner of 
strange positions in the vain hope of mitigating his sufferings. He is 
tormented by a constant desire to void urine, even though the blad- 
der be completely empty. Hematuria frequently accompanies the 
attack. Sometimes there is complete suppression of urine when both 
ureters are obstructed, or when only one kidney is serviceable. This 
occasions great danger of uraainia and death, though recovery some- 
times occurs after the existence of supression for many days. The 
return of secretion is often followed by an unusually copious discharge 



738 DISEASES OF GENITO-U RIN A R Y ORGANS. 

of urine. In the course of a few hours or days after the paroxysm of 
colic, the urine frequently contains sand or calculous masses. 

If the calculus remains fixed in the ureter it may, by perforation, 
excite peritonitis and all its accompanying symptoms. Pregnant 
women usually abort after an attack of renal colic. 

Renal colic is seldom terminated by a single paroxysm ; it is liable 
to frequent recurrence, sometimes throughout the whole course of life. 

The existence of renal sand in the pelvis of the kidney seldom pro- 
duces symptoms as severe as those which accompany, renal colic ; it 
occasions considerable uneasiness in the loins, and the urine frequently 
contains a considerable quantity of sediment, especially after drinking 
large quantities of pure water. Occasionally the urethra may become 
obstructed for a time by a mass of sand. 

The origin of renal calculi has been a subject of much speculation. 
In many cases there is an evident connection between catarrhal inflam- 
mation and the precipitation of calculous matter. Two classes of cal- 
culi may be recognized, to the first of which belong those concretions 
which are deposited in acid urine, e. g., uric acid, urate of sodium, 
oxalate of calcium, and cystin (primary calculi) : to the second class 
belong those concretions which are only precipitated in urine that has 
undergone alkaline decomposition, e. g., urate of ammonium, phosphate 
of calcium, and ammonio-magnesian phosphates (secondary calculi). 

Diagnosis. Renal colic, by which the existence of a calculus is 
generally indicated, may be distinguished from lumbago and from gas- 
tralgia by the accompanying changes in the urine ; from cancer or 
tuberculosis of the spinal column, by the location of the pain in the 
side, or along the course of the ureter, instead of being fixed in the 
spinal column ; from biliary colic, by the absence of jaundice, and by 
the location of the pain : from embolism of the renal artery, by the ab- 
sence of heart disease ; and from para-nephritic abscess, by the absence 
of swelling, and by other evidences of infiltration in the region of the 
kidney. The nature of the obstructive calculus must be inferred from 
the character of the urinary sediment and the reaction of the urine. 

Prognosis. Though renal calculi are seldom attended with imme- 
diate danger, the prognosis must be very cautiously expressed with 
regard to the future. 

Treatment. The course of treatment must have reference to 
prophylaxis, and to the relief of paroxysms of colic. The diet of the 
patient must be regulated so as to avoid all excesses in the way of 
animal food, wine and beer ; the food should not. however, be too 
largely of a vegetable character, since the vegetable salts are trans- 
formed within the body into carbonates, by which the urine may be 
rendered alkaline, thus favoring the formation of certain varieties of 
calculi. Obese and gouty persons must be strictly cautioned with re- 
gard to their diet ; and every inflammatory process involving the 
urinary passages must be subjected to appropriate treatment. 

In the presence of renal calculi it is desirable to effect their removal 
as speedily as possible : for this purpose an abundance of pure water 
should be drank ; water from the Poland Spring in Maine enjoys a 
high reputation for this purpose; distilled water also may be employed 



DISEASES OF THE BLADDEK. 739 

with equally good results. The fluid extract of hydrangea, in drachm 
doses every four hours, is sometimes followed by the expulsion of 
numerous calculi which have annoyed the patient for months or years. 
Uric acid concretions are benefited by the use of alkalies and alkaline 
mineral waters. The diiferent compounds of lithium enjoy a high repu- 
tation in connection with this class of renal calculi ; but it must not be 
forgotten that lithium salts are not long tolerated by the stomach. 
Lithia spring water, Vichy water, and other alkaline or alkaline-saline 
spring waters may be drank with great advantage during the period of 
one or two months, or even longer, if the treatment is occasionally in- 
terrupted, in order to give the stomach rest. 

Calculi composed of oxalic acid or of cystin, require the same general 
treatment by diet and exercise that is useful in the management of 
other varieties. Vegetables and fruits which contain oxalic acid must 
be avoided, e. g., rhubarb, spinach, and wood sorrel. Apollinaris water, 
Waukesha water, and other alkaline waters are useful. 

Phosphatic calculi may be treated by the use of the mineral acids, 
and carbonated waters. 

The paroxysms of renal colic require the use of morphine and atro- 
pine, hypodermically, and chloral hydrate in doses of half a drachm or 
a drachm, warm baths, and warmth in bed. Sometimes it becomes 
necessary to administer chloroform or ether. The bowels should be 
well opened with calomel and jalap (10 grains of each in one powder). 
After the calculus has entered the bladder, its final discharge may be 
facilitated by urinating while standing upon one's head. 

In severe and often-repeated cases of renal colic which depend upon 
the location of the calculus in the pelvis of the kidney, it may become 
necessary to resort to surgical measures ; of these, either nephrolithotomy 
or nephrectomy may be performed. The first operation is fatal in 
about ten per cent, of the cases ; the second is fatal in about forty-three 
per cent. 



CHAPTEE IV. 

DISEASES OF THE BLADDER. 



CHRONIC DISEASES OF THE BLADDER. 

Catarrh of the Bladder — Urocystitis Catarrhalis. 

Etiology. Catarrh of the bladder may be either primary or 
secondary, acute or chronic, mucous, purulent, hemorrhagic, or gan- 
grenous. 

Primary inflammation of the bladder is a rare disease, and is usually 
excited by injuries, irritants, or exposure to cold. Among injuries to 
which the organ is exposed may be mentioned the results of surgical 



740 DISEASES OF GBNITO-URINABY ORGANS. 

operation upon the pelv _'..>. ad all the varied event? of pregnancy 
and parturition among females. 

Among the irrit of vesical inflammation may be men- 

I the action of cantharides. oil of turpentine, and the balsams. 
The incautious use of urethral injections frequently leads to severe in- 
flammation of the bladder. In like manner the employment of sounds 
or catheters which have not been properly disinfected may be followed 
by similar results, through the introduction of bacterial agen:^ 
which inflammation is excited. In this way decomposition of the urine, 
and the liberation of ammonia may result from the entrance of bac- 
terium urea? and micrococcus urea? within the bladder. It is probable 
that inflammations which result from exposure to cold are excited by the 
opportunity thus given for the activity of those lowei _ nisms by 

. :h the pre sessis irousf 

Secon la \ . i :.':.■:■ is the most common form of vesical inflammation. 
It may be sed by stagnation of the urine, or by the extension of 

inflammation from other organs, or it may result from other diseases : : 
the bladder, or from general infective diseases. 

Cystitis is principally a disease of middle life and of old age. It is a 
rare event among children, but old people frequently experience the 
disease as a consequence of urinary stagnation produced by hypertrophy 
of the prostate gland. 

Pathological Anatomy. Catarrhal inflow - Ider 

presents different appearances, ace:: ling ::• its acute or chronic char- 
acter, and its extension as a diffuse or a circumscribed inflammation. 
Circumscribed cystitis usually invades the neck of the bladder or the 
trigonum. 

The mucous membrane in acute c</stitis presents the ordinary appear- 
ance of redness and swelling that characterizes mucous inflammations. 
The muscular coat of the organ is often thickened and softened. Some- 
times the external coats are also involved in the inflammatory pi 
The mucous surface is frequently abraded, and sometimes extensively 
ulcerated. Like other hollow organs, perforation of its wall m 
thus produced. In certain cases the mucous membrane undergoes 
necrosis and gangrene. Occasionally abscesses form in the wall of the 
bladder, and may discharge their contents in either direction. 

In chat " ~ * the mucous membrane is deeply stained with 

blood pigment, and the veins, especially in the neighborhood of the 
neck of the bladder, are dilated and varicose. The mucous membrane 
and submucous tissues _ :ly thickened. The muscular fibres 

- ierably hypertrophied. and not unfrequently the external serous 
coat is thickened and adherent to the neighboring organs. The : 
of the bladder is usually rednc : - • -times, however, it be- 

comes greatly dilated. When the vesical wall is thickened and dilated. 
it produce! i the bladder, and when the cavity 

is considerably reduced, the increased thickness of the wall constitutes 
what is terme Nol (infrequently the hyper- 

hied muscular fibres form an irregular network that bulj 
wame-like ridges beneath the mucous surface Not unfrequently a 
diverticulum mav be formed by the coalescence and distention of a 



DISEASES OF THE BLADDER. 



741 



number of such spaces, and the pouch is sometimes occupied by a stone 
of considerable magnitude. 

Symptoms. Acute cystitis frequently begins with chills and fever ; 
unusual vomiting and constipation may also exist. There is an intol- 
erable and constant inclination to void urine, even though the bladder 
be perfectly empty (vesical tenesmus). Evacuation of the bowels is 
attended with great pain. The region of the bladder is exceedingly 
sensitive to pressure, and painful sensations irradiate into all the neigh- 
boring organs and territories. When the neck of the bladder is prin- 
cipally involved, pain is especially severe in the perineum. Pressure 
through the rectum or vagina, and the introduction of the catheter or 
sound, is attended with great agony. The urine is scanty, high 
colored, and darkly colored. It frequently contains an abundance of 
mucus, and microscopical examination discovers numerous round cells, 
occasional red corpuscles, and vesical epithelium. Not unfrequently 
a considerable quantity of blood or pus is present, and the urine 
decomposes readily on exposure to the air. 

In many cases the urine has undergone alkaline fermentation in the 
bladder, and emits an alkaline odor when it is voided. Under such 
circumstances it colors red litmus paper blue, but the dependence of 
this reaction upon the presence of a volatile alkali is proved by the 
speedy return of a red color to the paper after it has been dried. The 
sediment contains large crystals of ammonio-magnesian phosphate, and 
urate of ammonia ; of these, the first exhibits its characteristic polygonal 
forms, while the second presents itself under the form of more or less 
regular spheroids, armed with prickles and thorny processes. (Fig. 
145.) Phosphate and carbonate of calcium are frequently present in 
the form of minute granules or dumb-bell-like mass. 

Fig. 145. 




Ammonio-magnesian (or " triple ") phosphates. Selected to show various forms. 

CFinlatsohO 



When alkaline urine contains pus the sediment exhibits a peculiar 
ropy and tenacious quality, by reason of the swelling of the pus 
corpuscles that is produced by the action of carbonate of ammonia. 

The formation of an abscess in the vesical wall is accompanied by 
chills and fever ; its evacuation is followed by a copious discharge of 



742 DISEASES OF GENITO-URIN AR Y ORGAN'S. 

pus with the urine, or through the rectum. Rupture into the peritoneal 
cavity occasions the symptoms of peritonitis ; and perforation of the 
vaginal wall originates a vesico-vaginal fistula. Gangrene of the 
bladder is indicated by the presence of gangrenous and offensive masses 
in the urine, and the occurrence of general prostration, which is 
followed by death. 

An acute catarrhal inflammation of the bladder may run its course 
in a few hours, or it may continue for many weeks. Recovery is the 
usual result, but sometimes the disease subsides into the chronic form. 

Chronic inflammation of the bladder may be the result of previous 
acute inflammation, or it develops gradually in a chronic form, as may 
be observed when a vesical calculus is its cause. The prominent 
symptoms are afforded by difficulty in the discharge of urine, and by 
changes in the quality of the secretion itself. 

Vesical pain and tenesmus are less -severe than in the acute form of 
the disease. Urine is voided with considerable difficulty, or it may 
continually dribble from the urethra, to the great annoyance of the 
patient. Sometimes the bladder becomes greatly distended with urine. 
Alkaline fermentation of the urine is a very common event. When 
the bladder has undergone concentric hypertrophy the patient is com- 
pelled to void small quantities of urine at frequent intervals, and the 
thickened wall of the organ can be felt through the rectum or the 
vagina. 

The disease may persist for many years, and is liable to acute ex- 
acerbations. It may be attended by the formation of vesical calculi, or 
by the extension of the inflammatory process to the ureters and kidneys. 
Life may be terminated by uraemia or ammonigemia. 

Diagnosis. Catarrhal inflammation of the bladder, whether acute 
or chronic, may be readily recognized by the difficulties that attend 
micturition, by the modified character of the urine, and by the in- 
creased sensitiveness of the vesical region. Alkalinity of the urine 
must be ascribed to alkaline fermentation, when the presence of ammo- 
nia is demonstrated by the fugitive change of color that is exhibited 
when red litmus paper is turned blue by immersion in the urine. The 
presence of fixed alkali derived from the vegetable salts in the food, is 
indicated by the permanent change of color that is exhibited by red litmus 
paper after immersion in urine which has been thus rendered alkaline. 
Ammoniacal urine also contains a great quantity of microorganisms. 

Prognosis and Treatment. The prognosis depends upon the 
causes of cystitis. It is comparatively favorable in acute forms of the 
disease. In the management of vesical inflammation prophylactic 
measures are of the utmost importance. Food and drink must be of a 
light and unirritating character. Milk and lime-water are especially 
valuable. All irritating drugs, spices, and excitants, should be pro- 
hibited ; and every surgical instrument that is to be used in connection 
with the diseased organ must be first subjected to thorough disinfection 
in a five per cent, solution of carbolic acid. Local diseases, strictures, 
vesical calculi, and other causes of inflammation must be removed, if 
possible. Acute cystitis may be treated for the most part with internal 
remedies, but chronic cystitis also requires local treatment. 



DISEASES OF THE BLADDER. 743 

Acute inflammation of the bladder requires repose in bed, the appli- 
cation of a warm poultice over the lower portion of the abdomen, and 
an abundance of warm tea (herb teas, infusion of uva ursi, or of buchu) 
to dilute the urine. The bowels must be kept open by the occasional 
use of calomel and jalap. Every morning and evening the patient 
should lie for half an hour in a warm bath, which must be maintained 
at a uniform temperature. If great pain is experienced in the perineum, 
it may be relieved by the application of four or five leeches ; some- 
times suppositories of opium are sufficient for this purpose. Belladonna 
should not be thus used, since it sometimes increases vesical pain. Ex- 
cessive mucous discharges may be diminished by the use of tannic 
acid, uva ursi, pareira brava, or small doses of balsamic remedies. The 
alkaline mineral waters are of service when no great amount of irrita- 
tion exists. If the urine has undergone alkaline fermentation, it was 
formerly the custom to administer mineral acids and benzoic acid ; 
recently, salicylic acid, chlorate of potassium, resorcin, and similar 
remedies have been advised. Especially useful is salol in doses of ten 
grains every three hours. Naphthalin should be avoided, since it some- 
times produces catarrhal symptoms in the urinary passages. ,Ohronic 
cystitis requires the same dietetic management as the acute disease. 
The bladder should be emptied every morning and evening with a soft 
catheter, after which it should be thoroughly irrigated with tepid water, and 
then injected with a four per cent, solution of nitrate of silver, which may 
be gradually increased in strength. Many other astringents and disinfect- 
ants have been similarly recommended, as may be learned from the text- 
books of surgery. Solutions of carbolic acid or of corrosive sublimate 
must not be used — they are too poisonous. The occurrence of alkaline 
fermentation in the bladder is the special indication for the use of dis- 
infectant injections (boracic acid, permanganate of potassium, etc.), and 
especially for the internal administration of salol. 

If, in spite of these methods, no relief can be procured, it may be- 
come necessary to open the bladder by an incision like that which is 
made in the operation for the removal of a vesical calculus. 

Eccentric hypertrophy of the bladder should be treated by frequent 
catheterization, electricity, and cold sponging, in order to invigorate 
the contractility of the organ. In cases of concentric hypertrophy, 
the patient should be instructed to retain the urine for at least two hours 
at a time, in order to dilate the cavity of the organ as much as possible. 

Cancer of the Bladder — Carcinoma Vesicae Urinariae. 

Etiology. Cancer of the bladder occurs more commonly among 
women than among men, during middle life. It is generally a secondary 
development of the disease, and is usually propagated from the neighbor- 
ing organs to the bladder. 

Pathological Anatomy. Vesical cancer presents all the varieties 
of carcinoma, but usually occurs in the form of an epithelial growth 
which may be diffused throughout the mucous membrane and submu- 
cous connective tissue, or may exist in the form of circumscribed tu- 
mors upon the inner surface of the bladder. The mucous membrane 



744 DISEASES OF G EXITO-U R I X A R V ORGANS. 

is involved in a condition of catarrhal inflammation ; and vesical 
calculi are sometimes present. As a result of ulceration, the walls of 
the bladder are frequently perforated, and the neighboring cavities are 
invaded. 

Symptoms. Cancer of the bladder can be crenerallv recognized bv 
investigation through the rectum or vagina, or by the discovery of can- 
cerous debris in the urine. Sometimes the surface of the tumor is in- 
crusted with mineral precipitates which yield a grating sensation when 
explored with a metallic sound, or touched with a catheter. Villous can- 
cers frequently throw off portions of their substance which appear in 
the urine and may be submitted to microscopical examination. 

When a cancerous tumor cannot be discovered in the bladder, or in 
the absence of cancerous masses from the urine, one of the most relia- 
ble symptoms of the disease consists in the occurrence of hoematuria. 
especially when that symptom is associated with cachectic conditions at 
an advanced period of life. The occurrence of enlarged glands in the 
groins is also an important symptom. Hematuria occurs as a conse- 
quence of stone in the bladder, it is true, but it is then usually ob- 
served after active exercise on the part of the patient, while cancerous 
hematuria commonly occurs during a period of perfect quiet. 

Pain is often experienced. It is usually most severe in the peri- 
neum, but it irradiates into all the neighboring regions, and differs from 
the pain that accompanies vesical calculus by the fact that it is not ag- 
gravated by movements of the body. In many cases, vesical tenesmus 
is experienced as a consequence of the associated catarrhal inflamma- 
tion. Sometimes there is retention of the urine, or dribbling of urine, 
when the urethral opening is temporarily or partially obstructed by the 
cancerous tumor. 

Cancer of the bladder generally runs its course within a few months, 
but it sometimes continues for three or four years. 

The disease is fatal, and death sometimes results from hematuria or 
from uraemia, or from dropsy and exhaustion, unless the peritoneum 
has been penetrated, when fatal peritonitis is excited. The extension 
of the disease to neighboring organs is attended with most distressing 
consequences. 

Diagnosis and Prognosis. The only difficulties that attend the 
diagnosis are associated with the differential diagnosis between cancer 
and vesical calculus, or chronic cystitis. The prognosis is always un- 
favorable. 

Treatment. The treatment must be symptomatic, and directed to 
the relief of pain and hemorrhage. Sometimes surgical measures for 
the removal of a cancerous tumor have been undertaken. For infor- 
mation regarding other tumors which may occupy the bladder, the stu- 
dent is referred to text-books on surgery. 

In the bladder are sometimes found foreign bodies which may have 
been introduced accidentally, or intentionally, from without, or may 
have found their way from the intestines or other passages through fis- 
tulous openings into the bladder. In this way gall-stones, seeds, hairs, 
and intestinal flatus have sometimes entered the bladder, and have been 
voided with the urine. 



DISEASES OF THE BLADDER. 745 

FUNCTIONAL DISEASES OF THE BLADDER. 
Enuresis Nocturna. 

Symptoms. Wetting of the bed at night is almost exclusively a 
disease of childhood. It usually ceases about the twelfth year of age. 
Urine is unconsciously voided by such children during deep sleep in the 
first two hours after retiring, or, occasionally, just before awaking in 
the morning. The accident occurs during periods that are associated 
with frequent remissions and exacerbations which are experienced more 
frequently during the winter than during the summer. Children who 
suffer from this misfortune are generally sad and debilitated, and are 
easily excited by emotion, or by unusual exertion of any kind. Under 
such circumstances an involuntary discharge of urine is not uncommon. 

Etiology. In many cases wetting of the bed is the result of defective 
training in early childhood. Sometimes it is due to errors of diet and 
indigestion, consequent upon late suppers and the excessive consumption 
of liquids. Warm beds and heavy blankets favor the accident. 

In certain cases an irritable condition of the urinary passages occa- 
sions enuresis. It is frequently observed in cases of phimosis, or when 
little polypoid excrescences appear about the orifice of the female urethra. 
Sometimes it is excited by the existence of pyelitis or vesical calculus. 
In other cases thread-worms irritate the rectum and neck of the bladder, 
and thus originate the difficulty. 

But, in many cases, the disorder is a symptom of serious constitu- 
tional disturbances. In certain instances it is probable that it represents 
a masked form of nocturnal epilepsy ; and sometimes in adult patients 
the disorder is a forerunner of dangerous diseases of the brain or spinal 
cord. 

Treatment. Children who are so unfortunate as to be troubled 
with nocturnal enuresis must be taught to empty the bladder at certain 
definite hours of the day and night, and they should be awakened and 
taken out of bed for that purpose during the early portion of the night. 
Their supper should consist of light easily digested food, with the 
smallest possible quantity of liquid. The bed should be furnished with 
a hair-mattress and thin bedclothes, and the patient should be taught 
to lie upon one side instead of upon the back, since that position favors 
the involuntary discharge of urine. If the child be troubled with worms, 
vermifuge remedies should be prescribed. Pale and debilitated patients 
should take half a teaspoonful of the syrup of iodide of iron three times 
a day. Cold baths, the use of the flesh-brush, and country air, or the 
sea-shore, should be prescribed. If there be any suspicion of epilepsy, 
bromide of potassium should be given in ten-grain doses three or four 
times a day. Narcotics, such as atropine, belladonna, and chloral hy- 
drate are frequently used. Nux vomica is recommended when urine 
dribbles frequently during the daytime. Cantharides blisters over the 
sacrum, and the internal use of the tincture of cantharides are frequently 
of service. The application of faradic electricity is also exceedingly 
beneficial. One electrode should be placed in the rectum and the other 



746 DISEASES OF GENITO-U RIN AR Y ORGANS. 

upon the perineum or upon the hip, and the current should be passed 
for five or ten minutes every day or two. Galvanization of the spine is 
also useful. 

Hyperesthesia and Spasm of the Bladder — Hyperesthesia et 
Spasmus Vesicae TJrinariae. 

Symptoms. Vesical hypercesthesia is indicated by the existence of 
an impulse to the passage of urine whenever any small quantity of the 
fluid has accumulated in the bladder. It is frequently associated with 
other nervous symptoms, such as headache, pain in the back, etc. The 
urine is generally pale and watery, or it may be excessively acid. Vesi- 
cal spasm may affect either the detrusor muscle, or the sphincter muscle 
of the bladder. In the first instance there is a constant desire to void 
urine of a pale and watery character and low specific gravity, such as 
occurs frequently in connection with hysterical paroxysms. In the 
second instance the act of micturition is attended with difficulty, and is 
frequently interrupted by spasmodic contractions of the sphincter muscle 
that are often attended with great pain, irradiating into the perineum 
and neighboring regions. Sometimes both muscles are affected at the 
same time, producing an agonizing desire to urinate, though no success- 
ful result attends the effort. 

Etiology. Hypercesthesia and spasm of the bladder are encountered 
among delicate and nervous people who have lived imprudently, or have 
indulged in excessive bodily or mental exercises. Sometimes serious 
disorders of the brain or spinal cord exist as underlying causes of these 
symptoms. In other instances they are excited through the interven- 
tion of reflex irritation that has its origin in other organs. 

Treatment. Such local causes as admit of removal should be dis- 
covered and relieved, if possible. For this purpose the alimentary canal 
and the pelvic organs should be carefully examined, and laxatives, or 
anthelmintics, should be prescribed. Pale and debilitated persons 
should take iron and tonics. For the relief of a paroxysm of painful 
spasm, the patient should be placed in a warm bath, and warm fomen- 
tations should be applied to the perineum and to the lower portion of 
the abdomen. Hypodermic injections of morphine, without atropine 
or belladonna, may be employed, or chloral hydrate may be adminis- 
tered. The use of electricity affords considerable benefit in severe 
and obstinate cases; the negative pole should be placed over the sym- 
physis pubis, with the positive pole upon the sacrum or perineum. 

Paralysis of the Bladder — Cystoplegia. 

Etiology. Paralysis may affect either the detrusor muscle, or the 
sphincter, or both muscles of the bladder. The disorder is frequently 
a symptom of diseases involving the brain and spinal cord. It some- 
times occurs in connection with hysteria, and it may be observed in 
severe cases of infective disease. Sometimes it is a result of marasmus, 
or physical exhaustion, or venereal excess. It may occur as a tempo- 
rary consequence of opium poisoning, and it is sometimes observed as 



DISEASES OF MALE ORGAN'S OF GENERATION. 747 

the result of long-continued retention of the urine. Injuries, severe 
shock, and violent inflammation of the bladder itself, may occasion a 
paretic or paralytic condition of the organ. 

Symptoms. Paralysis of the detrusor muscle of the bladder is 
indicated by great distention of the organ, which sometimes rises as 
high as the ensiform cartilage, and has been mistaken for an abdominal 
tumor, or for the pregnant uterus. In such paralytic conditions the 
urine can only be voided by the aid of voluntary contraction on the 
part of the abdominal muscles, or by pressure with the hand over the 
bladder. 

Paralysis of the sphincter muscle of the bladder is indicated by a 
continual dribbling of urine. When both muscles are paralyzed, a combi- 
nation of symptoms exists in which the urine dribbles from an over- 
distended bladder. 

Diagnosis and Prognosis. Paralysis of the bladder may be dis- 
tinguished from inflammatory and spasmodic conditions of the organ by 
the absence of pain, and by the non-existence of any obstruction in 
the urinary passages. The prognosis depends upon the cause of the 
disease ; it is especially serious when associated with chronic catarrhal 
inflammation, and decomposition of the urine, which may lead to urae- 
mia or ammonisemia. 

Treatment. Paralysis of the detrusor muscle creates the necessity 
for frequent use of the catheter in order to prevent stagnation and 
decomposition of the urine in the bladder. If the sphincter muscle be 
paralyzed, it becomes necessary to wear a rubber urinal into which the 
urine may find its way. 

In order to promote the restoration of contractility in the paralyzed 
muscle, it is important to employ cold douches over the region of the 
bladder, with friction upon the abdomen and sacrum, and the applica- 
tion of electricity. The positive pole should be applied to the loins, 
and the negative pole to the symphysis pubis when the detrusor muscle 
is paralyzed, or upon the perineum when the sphincter muscle is 
enfeebled. Faradic electricity is also useful. By the use of slender 
electrodes, one pole may be carried through the urethra into the blad- 
der. Hypodermic injections of strychnine should also be employed 
once or twice daily. 

The general causes upon which vesical paralysis depends also require 
appropriate treatment. 



CHAPTEE V. 

DISEASES OF THE MALE ORGANS OF GENERATION. 

Impotence — Impotentia Virilis. 

Excluding from view those cases in which impotence is the result of 
congenital defects, the disease consists in the impossibility of copula- 
tion. This may result from diseases of the testicle which have de- 



748 DISEASES OF GENITO-URINARY ORGAN'S. 

stroyed its function, and have thus abolished that power of erection 
upon which successful copulation depends. A similar failure sometimes 
follows chronic diseases of the digestive organs and other causes of mal- 
assimilation and imperfect nutrition. It may be temporarily occasioned 
by certain poisons, like cannabis indica, potassium bromide, camphor, 
lupulin, salicylic acid, opium, and coifee. The excessive use of tobacco 
not unfrequently leads to an early loss of sexual power. It is often 
dependent upon masturbation, premature or inordinate debauchery, 
and neurasthenia. 

Closely allied with this last condition are cases of impotence that 
have their origin in psychical causes. Violent emotions of a depressing 
character are frequently followed by temporary loss of sexual appetite 
and efficiency. The anxiety that attends inexperience during the first 
attempt at copulation often causes total collapse and failure under such 
circumstances. But this need not be any reason for discouragement, 
for after the novelty of intimacy under peculiar conditions has been 
dissipated by longer acquaintance, abnormal excitement and consequent 
inhibition of the copulative process are no more experienced. Leaving 
out of mind the danger of infection with gonorrhoea and syphilis, very 
imprudent is the method of procuring skill by experiment in eorpore 
vili, for knowledge that is acquired in the slums often fails utterly in 
the presence of a virtuous and adorable bride. Patience, moderation, 
and time are sufficient remedies in all such cases. The applicant for 
medical advice usually needs nothing but encouragement. Especially 
should he be cautioned against the popular delusion that complete in- 
tromission must be effected at the first attempt, even at the risk of 
painful laceration of the vulva, in order to avoid subsequent dangers to 
husband and wife. Anaemic, neurasthenic, and exhausted patients 
should, of course, be treated on general principles, Diet, change of 
air and occupation, cold sponge-baths, massage, and electricity are the 
most useful agents. 

Aspermatism. 

It sometimes happens that although the act of copulation be attended 
with no difficulty, it is either not accompanied by seminal ejaculation, 
or the discharge takes place only after the subsidence of rigidity in the 
male organ, so that impregnation does not follow. This condition may 
have its origin in a gonorrhoea! inflammation by which the ducts are 
constricted, and their compression is increased during the period of 
erection. Sometimes the difficulty consists in a long and tight prepuce 
(phimosis), and is promptly relieved by circumcision. In other cases 
the prostate gland is either enlarged so as to occlude the ejaculatory 
ducts, or it may be atrophied and deformed in such a way that the 
seminal fluid is thrown backward into the bladder. Occasionally, the 
seminal vesicles are diseased or are so obstructed that their contents 
cannot escape. These various conditions may result from local injury ; 
but in certain cases the difficulties are of a psychical nature. This is 
usually the fact when the patient is of a nervous and debilitated con- 
stitution. It is not uncommonly observed among such persons when 



DISEASES OF MALE ORGANS OF GENERATION. 749 

they have previously exhausted themselves by masturbation or venereal 
excesses. 

When the disease is not dependent upon irremediable conditions of 
congenital or acquired origin, it may be overcome by the removal of 
its causes, and by general hygienic and constitutional treatment, inclu- 
ding cold baths, massage, outdoor life, restoratives, and tonics. 

Azoospermia. 

Azoospermia signifies the absence of spermatozoa from the seminal 
fluid. This may be caused by injuries or diseases that have destroyed 
the functions of the testicles, or it may be due to conditions that pre- 
vent the passage of semen from the glands to the seminal vesicles. In 
such cases the ejaculated fluid may possess the physical appearance and 
odor of semen, but it contains no spermatozoa. 

The disease can only be cured by the removal of its cause ; and when 
that is impossible, no relief can be obtained. 

Spermatorrhoea. 

Symptoms. The well-known occurrence of nocturnal emissions can- 
not be regarded as a disease unless they recur so often as to produce 
fatigue and depression. During periods of continence they constitute 
the normal method of evacuating the seminal organs, and the process 
by which this is effected during sleep is as physiological as the analo- 
gous process of menstruation. Unlike that function, however, there is 
no uniform recurrence of the incident. It is subject to wide differences, 
so that everyone becomes a law to himself. Perhaps once in five or 
six nights may be regarded as the healthy average for young and vigor- 
ous men during the period of greatest sexual power. But if the emis- 
sions follow one another every night, or several times during a 
night, and especially if they occur as an involuntary accident during 
the waking hours, they must be considered as evidence of ill-health. In 
the worst forms of the disease the flow of semen occurs without previous 
excitement or erection, and is wholly devoid of pleasurable sensations. 
The spermatozoa are imperfectly developed, and are mixed with an ex- 
cessive quantity of mucous liquid. Sometimes the urine, also, becomes 
charged with the substance. The trickling that sometimes follows defe- 
cation, in consequence of pressure of the feces upon the seminal vesicles, 
is a comparatively trifling matter, since it merely indicates a relaxed 
condition of the ducts. 

Many cases of spermatorrhoea occur among neurasthenic and 
hypochondriacal patients. To such it is usually a source of great 
mental anxiety, and they refer the majority of their symptoms to that 
cause. 

Etiology. Chief among the causes of spermatorrhoea must be 
placed the practice of masturbation. By this unnatural form of excite- 
ment, a condition of irritable weakness is established, so that slight 
causes produce an inordinate reflexive response. Venereal excesses 
also occasion a similar state of things. Sometimes the condition is due 



750 



DISEASES OF GENITO-URINARY ORGANS. 



Fig. 141 



to phimosis, and to other causes of irritation about the glans penis, or 
in the course of the urinary passages. But in certain cases the cause is 
located in the brain or in the spinal cord. The early irritative stage 
of cerebral or spinal disease is often accompanied by an increase of 
sexual excitement. Witness the exaggerated appetite and frequent 
erection that sometimes may be observed during the initial period of 
tabes dorsalis and of progressive paresis. Injuries of the dorsal portion 
of the spinal cord are sometimes followed by a similar result. 

Spermatorrhoea sometimes occurs as a consequence of the irritability 
that is developed during the course of long and wasting diseases, like 
pulmonary tuberculosis, diabetes, etc., especially if the patient be of a 
neurotic and excitable character. Children who wet their beds at night 
are frequently victims of spermatorrhoea in later life. 

Diagnosis The nature of the discharge can be readily determined 
by the aid of the microscope, but whether it be a physiological 

occurrence or a case of pathological 
spermatorrhoea must be decided by 
reference to the history and condition 
of the patient. (Fig. 146.) 

Treatment. The treatment of the 
disease must have reference to its cause. 
General hygienic care, good diet, a 
hard bed, and the habit of lying upon 
the side rather than upon the back, must 
be secured. Cold baths, the use of 
the flesh-brush, and an outdoor life 
are desirable. The alimentary canal 
must be kept in a healthy condition, 
and stimulating laxatives, excluding 
aloes, are often needed. Iron, com- 
pound tincture of gentian, and other 
restoratives and tonics may be prescribed for pale and feeble patients. 
Strychnine must be used cautiously by reason of its power to excite and 
to overstimulate the sexual apparatus. Camphor, lupulin, and similar 
drugs have been recommended for the relief of irritability, but their 
utility is very limited. When the urethra is inordinately tender, benefit 
sometimes accrues from the daily introduction of a cold steel sound. 
Massage and electricity are often of great service. Marriage should not 
be advised unless the health be sufficient to warrant the practice of copu- 
lation, and then great moderation should be recommended. 




Spermatozoa. (Roberts.) 



Prostatorrhoea. 

Prostatorrhoea signifies an involuntary discharge of the prostatic 
secretions into the urethra. The disease occurs as a result of the 
enlargement of the prostate gland in old age, or as a result of the ex- 
tension of catarrhal inflammation into its ducts. The discharge fre- 
quently occurs during the act of defecation, or coughing, or straining, 
by which the prostate gland is subjected to pressure. The liquid 



DISEASES OF MALE ORGANS OF GENERATION. 751 

consists of a milky, mucous fluid, like thin starch, and it emits a 
seminal odor. It contains cylindrical epithelial cells, round cells, 
amyloid bodies, and various pigmentary or granular masses. On the 
addition of a one per cent, solution of phosphate of ammonia, crystals 
or rosettes that resemble the so-called asthma crystals, are precipitated, 
together with the characteristic forms of ammonio-magnesian phosphate. 
The treatment of prostatorrhcea consists in the removal of local 
catarrhal disorder, and in the employment of such general measures 
as are useful in spermatorrhoea. 



PART X. 

DISEASES OF THE NERVOUS SYSTEM. 



CHAPTEE I. 

DISEASES OF THE PERIPHERAL NERVES. 1 



DISEASES OF THE MOTOR NERVES. PARALYSIS OF THE 
MOTOR NERVES. 

Facial Paralysis — Paralysis Nervi Facialis. 

Etiology. Peripheral facial paralysis consists in a paralysis of 
the peripheral branches of the facial nerve, produced by any cause that 
operates externally to the origin of the nerve trunk in the facial 
nucleus under the floor of the fourth ventricle. Peripheral paralysis 
is of intra-cranial origin when it is dependent upon disease or injury 
of the nerve between its origin and the Fallopian canal ; and it is 
extra-cranial when dependent upon injury or disease of the portion that 
lies outside of that passage. 

Chief among the causes of peripheral paralysis is exposure to cold on 
the part of individuals who are liable to rheumatic disorders. In 
other cases paralysis is dependent upon injuries which may be occa- 
sioned by falls, blows, bruises, compression of the nerve with forceps 
during delivery, operations upon the parotid gland, hemorrhages into 
the Fallopian canal, etc. Sometimes inflammatory diseases, abscesses, 
neoplasms, and tubercular processes in the neighborhood of the nerve, 
may result in its paralysis. It is a not uncommon event in the course 
of diseases involving the ear ; accumulations of wax in the external 
ear, catarrhal inflammations of the middle ear, and tubercular processes 
involving the petrous portion of the temporal bone, exostoses, hemor- 
rhages, aneurisms of the cerebral artery at the base of the brain, and 
any other process by which the nerve trunk can be subjected to com- 
pression, may produce facial paralysis. 

In certain cases the disease exists as a consequence of acute infective 

1 For information regarding the diseases of the second, third, fourth, sixth, and 
eighth cranial nerves, the student is referred to the standard text-books on the Eye 
and Ear. 

48 



754 DISEASES OF THE NERVOUS SYSTEM. 

diseases. It is not uncommon in association with syphilis, or as a 
result of lead poisoning. The disease is observed more frequently 
among men than among women, because they are chiefly exposed to its 
exciting causes. 

Pathological Anatomy. The pathological alterations that are 
exhibited as a consequence of facial paralysis, resemble those which 
follow nerve-section in the lower animals, viz., breaking up of the 
medullary sheath, disappearance of the axis-cylinders, and proliferation 
of the nuclei in the walls of the sheath of Schwann. The paralyzed 
muscles undergo fatty degeneration of the muscular fibres, and an in- 
crease of the interstitial connective tissue. 

In slight and transitory forms of paralysis the pathological changes 
are undoubtedly limited to inflammatory swelling of the connective 
tissue in the nerve trunk, by which is occasioned temporary compres- 
sion of the nerve fibres. If such inflammatory swelling involve a 
portion of the nerve within the Fallopian canal, it is easy to understand 
how readily a slight change may be followed by complete disappearance 
of function. 

Symptoms. Since the facial nerve at its point of departure from 
the medulla oblongata receives secretory nerve fibres, it is evident that 
its paralysis must be accompanied by disturbances of secretion in the 
salivarv glands to which it sends branches. Since at the geniculate 
ganglion the facial nerve receives by the way of the great superficial 
petrosal nerve, fibres from the trigeminal nerve which become merged 
in the chorda tympani nerve and are distributed to the anterior two- 
thirds of the tongue, it is evident that facial paralysis must occasion a 
certain amount of disorder in the sense of taste. And since the facial 
nerve sends motor fibres through the stapedius nerve to the stapedius 
muscle, it is evident that its paralysis must also affect the sense of 
hearing. 

Facial paralysis frequently commences abruptly, or it may be pre- 
ceded by painful sensations in the ear and in the side of the face. "When 
it is originated by chronic diseases of the ear or of the temporal bone, 
the symptoms of those disorders are observed for a long time previous 
to the incidence of paralysis 

Loss of motion in the muscles of the face is the most conspicuous 
symptom of facial paralysis : the affected side is rendered immovable, 
and the cutaneous folds are less conspicuous than usual ; laughter and 
other facial contortions produce no effect upon the diseased side : the 
forehead cannot be wrinkled, and the eye cannot be closed upon the 
paralyzed side, by reason of paralysis of the frontal and orbicularis 
muscles ; tears trickle down the cheek in consequence of paralysis of 
Horner's muscle, by which the eyelids should be kept in apposition 
with the eyeball, consequently the surface of the conjunctiva becomes 
dry and liable to inflammation and ulceration : the tip of the nose and 
the orifice of the mouth are drawn toward the healthy side, since the 
non-paralyzed muscles are no longer balanced by their natural an- 
tagonists ; the nasal passage upon the paralyzed side is unnaturally dry 
because the tears do not find their way through the tear-ducts into the 
nose , the naso-labial fold is obliterated, the angle of the mouth droops 



DISEASES OF THE PERIPHERAL NERVES. 755 

and hangs partly open upon the paralyzed side, so that saliva frequently 
trickles from that corner of the mouth. Articulation is defective, be- 
cause it is no longer possible to adjust the lips for the utterance of 
labial sounds. The movements of the tongue and of the jaws experi- 
ence no change, since those organs are innervated by the trigeminal 
nerve, and paralysis of the stylohyoid muscle and of the posterior belly 
of the digastric muscle exercises no appreciable influence upon their 
function. The act of chewing is, however, attended with some degree 
of difficulty by reason of paralysis of the buccinator muscle, a condi- 
tion that permits the intrusion of food between the cheek and the jaw^ ; 
sometimes the paralyzed cheek is severely bitten in consequence of its 
collapse between the teeth. The external auricular muscles are also 
incapable of movement ; and all reflex and associated movements that 
depend upon the facial nerve are rendered impossible by its peripheral 
paralysis, though they are retained when paralysis is caused by central 
lesions between the nucleus of the nerve and the cerebral hemispheres. 

Auditory disorders which occur in connection with facial paralysis 
may be dependent upon the special diseases in the cavity of the ear or 
in the petrous portion of the temporal bone by which the paralytic af- 
fection is produced. But in simple nerve paralysis without accompany- 
ing aural disease, the auditory function is exalted by the paralytic con- 
dition of the stapedius muscle. Under such circumstances, the unbal- 
anced activity of the tensor tympani muscle, which receives its nervous 
supply from the trigeminal nerve through the medium of the otic gan- 
glion, causes an increase of delicacy in the function of hearing. 

When the cause of paralysis involves that portion of the facial nerve 
that contains fibres derived from the trigeminal nerve through the me- 
dium of the sphenopalatine ganglion, the sense of taste is lost in the 
anterior two-thirds of the corresponding border of the tongue ; and 
sometimes a peculiar metallic taste is perceived in the mouth. This 
condition of the tongue may be tested by causing the patient to pro- 
trude the organ while it is touched with a brush or glass rod that has 
been dipped in solutions of quinine, acetic acid, salt, or sugar. When 
the experiment is carefully performed, the results are very instructive. 
The loss of tactile sensibility in the tongue may be demonstrated by 
pressure upon its surface with the head of a pin while the patient keeps 
his eyes closed. 

Diminution in the secretion of saliva, and dryness of the paralyzed 
portion of the mouth are commonly observed. 

In consequence of the paralysis of those fibres of the facial nerve 
which pass through the sphenopalatine ganglion and are distributed to 
the muscles of the uvula and soft palate, the palatine arch upon the 
paralyzed side is depressed, and the uvula is drawn toward the healthy 
side of the fauces, though this sometimes occurs independently of paral- 
ysis. Peripheral paralysis is associated with changes in the electrical 
reactions of the paralyzed nerves and muscles ; in connection with 
which three grades of severity may be easily distinguished. Since the 
electrical reactions are uniform in all similar cases of paralysis, the de- 
scription which applies to the consequences of facial paralysis w T ill be 
equally applicable in other forms of the disease. 



756 



DISEASES OF THE NERVOUS SYSTEM. 



In slight forms of paralysis the muscles exhibit very little change 
in their reaction to faradic and galvanic currents ; and very little, if 
any, difference is perceptible when either the nerves or the muscles un- 
dergo electrical excitation. (Fig. 147). The paralyzed nerves and 
muscles are perhaps a little more excitable than those of the healthy 
side ; and if this proportion exists after the seventh day, recovery may 
be expected within two or three Aveeks. 



9 "3 Sg 



t5 a § 2 



- -s I =.'jj z -i' '- \ z li \\\\ I i i' I ~y i r 1 




Jn cases of moderate severity a certain amount of degeneration 
occurs in the axis-cylinders and medullary sheaths of the nerve fibres, 
and they become less capable of transmitting impulses to the muscles. 
The muscles during the second week also undergo degeneration. The 
muscular fibres diminish in size, their stride become less conspicuous, 
their nuclei increase in number, and the interstitial connective tissue 



DISEASES OF THE PERIPHERAL NERVES. 757 

becomes more abundant. As a consequence of these changes, the 
muscles are unable to contract under the influence of the instantaneous 
excitement that is produced by the faradic current, which consists of a 
rapid succession of sharply interrupted impulses. Under the influence 
of the comparatively slow and continuous galvanic current the muscu- 
lar fibres can still react, though in a somewhat sluggish and tetanoid 
manner. In this condition, at the commencement of paralysis electri- 
cal excitation of the paralyzed nerve demonstrates a slight increase of 
excitability ; but, at the end of the first week, a notable diminution of 
reaction with both forms of electricity is evident. No further change 
occurs before the commencement of recovery, after which a gradual 
return to normal conditions is observed ; but, when electrical excitation 
is directly applied to the muscles themselves, different consequences at 
once appear, and develop progressively during the second and third 
weeks. At the end of the first week there is manifestly a great and 
increasing loss of excitability under the faradic current. At the same 
time the reaction to the galvanic current is somewhat diminished ; but, 
during the course of the second week, it displays considerable increase, 
and the paralyzed muscles exhibit slowly developed and moderate con- 
tractions under the influence of a current that is insufficient to arouse 
contraction in a healthy muscle. Thus a galvanic current of two 
milliamperes may suffice to excite contraction in the paralyzed 
muscle, while a current of four or five milliamperes might be 
necessary to excite the corresponding muscle upon the healthy side. 
Besides this quantitative change in the excitability of the muscle a 
qualitative change in its reaction becomes apparent. When a healthy 
muscle is excited by the aid of the galvanic current of progressively 
increasing strength, its reactions may be represented as follows : 

Cathodal closing contraction (C C C) with weak currents. 

Anodal closing contraction (A C C) with stronger currents. 

Anodal opening contraction (A C) with strong currents. 

Cathodal opening contraction (C C) with strongest currents. 

But when similar currents are applied to a paralyzed muscle that is 
undergoing degeneration, the reactions are reversed, and A C C may 
take the place of C C C, and by a similar reversal C C will take the 
place of A C. 

Under such circumstances facial paralysis requires from four to eight 
or ten weeks for its recovery. Not unfrequently the power of voluntary 
motion returns before the galvanic reactions resume their normal char- 
acteristics. This is supposed to depend upon the restoration of the 
medullary sheaths of the nerve fibres, by which they are rendered 
competent to convey voluntary impulses to the muscles. 

The severest forms of peripheral paralysis of the facial muscles are 
attended by a rapid disappearance of reaction to both forms of elec- 
tricity when applied to the nerves. Direct electrical excitation of the 
muscles, however, is followed by the qualitative and quantitative changes 
that have just been described. In such cases complete recovery may 
never occur, or at least one or two years will be requisite for its accom- 
plishment. Not unfrequently the paralyzed muscle becomes contrac- 
tured so that the face appears as if drawn toward the paralyzed side. 



758 



DISEASES OF THE XERVOUS SYSTEM. 



The sensibility of the skin is almost always preserved upon the 
paralyzed side, except in cases where the peripheral lesion affects 
the terminal fibres of the nerves at the points of inosculation with the 
terminal filaments of the sensitive trigeminal nerve. Vasomotor dis- 
turbances are rarely observed. 

Double facial paralysis (Fig. 148) is an uncommon event, though it 
has occasionally been observed either as a consequence of double 



Fig 


148. 










■ 




' :i 


9HBBH£^ 




n 


A 


<*.. 






Jt 


^d 


i 


y 



Double facial paralysis. The patient is represented in an only partially successful 
attempt to close the eyelids. (Rush Med. Coll. Clinic.) 



peripheral paralysis, or as a consequence of peripheral paralysis involv- 
ing one side of the face, while the other is paralyzed by a central lesion. 

Diagnosis. Peripheral facial paralysis may be distinguished from 
facial paralysis that is caused by central lesions, by the fact that all 
the branches of the facial nerve are equally paralyzed, while in central 
paralysis the frontal branch of the nerve escapes, and the eyelids can 
be completely closed, except in disease of the pons Varolii which 
injures the trunk of the nerve. In cases of central paralysis the power 
of reflex and associated movement of the muscles is retained, and the 
electrical excitability of the nerves and muscles remains unchanged, or 
is sometimes increased at first. Central paralysis is also, in the majority 
of cases, associated with paralysis of the extremities upon the same side, 
except in cases of crossed paralysis. The history of the case should 
also assist in the differential diagnosis. 

The seat of the lesion by which peripheral paralysis of the facial 
nerve is occasioned, may be easily determined by a consideration of 
its anatomical relations. When the lesion occurs outside of the stylo- 
mastoid foramen, only the facial muscles are paralyzed. When the 
lesion occupies the outermost portion of the Fallopian canal below the 



DISEASES OF THE PERIPHERAL NERVES. 759 

origin of the chorda tympani nerve, the external muscles of the ear and 
the occipital muscle, which are innervated by the posterior auricular 
nerve, are also paralyzed. When the lesion is situated between the origin 
of the chorda tympani nerve and the stapedius nerve, besides the already 
noted paralysis, will occur disturbances of taste and of salivary secre- 
tion. When the lesion is situated between the origin of the stapedius 
nerve and the geniculate ganglion, disturbances of hearing are pro- 
duced through paralysis of the stapedius muscle which now enters the 
previous group. When the lesion is situated in the geniculate 
ganglion itself, the great superficial petrosal nerve is paralyzed, and 
the muscles of the soft palate, which are innervated by it through the 
intervention of the spheno-palatine ganglion, are also paralyzed. 
When the lesion is situated between the geniculate ganglion and the 
root of the nerve, there is paralysis of all the muscles to which the 
branches of the nerve are distributed, and disturbance of salivary secre- 
tion, but the sense of taste is retained, since the passage of sensory 
fibres from the trigeminal nerve through the intra-Fallopian portion of 
the facial nerve and the chorda tympani is not affected. 

Prognosis. The duration of facial paralysis is exceedingly varia- 
ble. When dependent upon tuberculosis involving the petrous portion 
of the temporal bone, or after injuries of a permanent character, 
recovery cannot be expected. Permanent paralysis finally leads to 
atrophy of the skin and muscles of the face. Relapses are not un- 
common after recovery, when the disease is dependent upon the exist- 
ence of the rheumatic diathesis. 

Treatment. When dependent upon syphilis, facial paralysis 
requires the use of iodide of potassium and mercury ; when caused by 
cicatricial tissues or other surgical diseases, operative interference is 
necessary. Rheumatic forms of paralysis require the use of warm 
baths, warm fomentations, salicylic acid (10 grains every hour until the 
ears ring), or iodide of potassium in five-grain doses three times a day. 
The only local application that affords much benefit is the electrical 
current ; the anode may be applied from two to five minutes over the 
mastoid process upon the paralyzed side, while the cathode rests upon 
the opposite process. A weak current that produces neither pain nor 
dizziness must be employed. W r hen the paralyzed muscles react under 
the faradic current they should be exercised by the application of a 
well-moistened electrode at an indifferent point, e. g. s over the sternum, 
while with the other pole each muscle is in turn excited. The point of 
the electrode should be moved from the motor point along the whole 
length of the muscle. Strong currents must be avoided, and no treat- 
ment should be prolonged beyond five minutes. The galvanic current 
may be employed in the same way when the muscle will no longer 
react under the faradic current. Muscular contracture requires simi- 
lar electrical treatment, and massage is sometimes beneficial. 

Paralysis of the Motor Portion of the Trigeminal Nerve — 
Paralysis Rami Tertii Nervi Trigemini. 

The motor portion of the trigeminal nerve is distributed to the 
muscles of mastication, viz. : the temporal, masseter, and pterygoid 



DISEASES OF THE NERVOUS SYSTEM. 

muscles, the anterior belly of the digastric muscle, the ruylo-hyoid. 
hyoid, tensor tyinpani. and the tensor palati muscles. Peripheral paral- 
ysis of these muscles is a rare event, though it sometimes occurs as a 
consequence of intracranial diseases. The temporal and ma- 
muscles on the paralyzed side no longer bulge under the finger during 
the act of mastication, and in consequence of paralysis of the pterygoid 
muscles the jaw is drawn toward the paralyzed side, and cannot be 
voluntarily carried toward the healthy side. When paralysis involves 
both sides, the lower jaw drops down, and the mouth hangs open. Dis- 
orders of sensation in the region of the trigeminal distribution are fre- 
quently observed. 

The treatment depends upon the cause, and consists largely in the 
local application of electricity. 

Paralysis of the Spinal Accessory Nerve — Paralysis Nervi 

Accessorii. 

Peripheral 'paralysis of the spinal accessary nerve may be produced 
by exposure to cold, by injuries, tumors, abscesses, cicatricial tissue in 
the neck, diseases of the cervical vertebra?, and occasionally by intra- 
cranial compression of the nerve. 

Since a considerable portion of the nerve is united with the pneumo- 
gastric nerve, it forms a constituent portion of those branches which are 
distributed to the pharynx, and. through the recurrent laryngeal nerve, 
to the muscles of the larynx. The external portion of the accessory 
nerve is distributed to the sterno-cleido-mastoid and trapezius muscles. 

When the sterno-cleido-mastoid muscle is paralyzed, the fa: 
drawn toward the paralyzed side, and the chin is turned upward by 
the action of the non-paralyzed muscle. After a time the paralyzed 
muscle becomes atrophied from disuse, and the healthy muscle becomes 
contractured. so that the head remains in a fixed position. When both 
muscles are paralyzed, the movement of the head is attended with 
difficulty. 

Unilateral paralysis of the tra uscle causes the shoulder-blade 

to droop upon the paralyzed side, and the posterior border of the scapula 
stands further away from the spinal column than the corresponding 
bone. The upper internal angle of the scapula is also drawn forward 
and downward by the weight of the arm. and by the contraction of the 
rhomboid and levator scapulae muscles. Shrugging of the shoulder and 
retraction of the shoulder-blade can scarcely be accomplished, since 
those muscles alone take part in the act. It is also impossible to raise 
the arm easily above a horizontal level, since the shoulder-blade can no 
longer furnish an advantageous fulcrum for the movement of the 
brachial lever. 

Treatment. The treatment must be conducted on general prin- 
ciples, including the daily use of electricity. 

Paralysis of the Hypoglossal Nerve — Glossoplegia. 

The hypogl ve is distributed to the lingual muse". - 

glossus, genioglossus. styloglossus, lingualis) to the hyoid muscles 



DISEASES OF THE PERIPHERAL NERVES. 761 

(geniohyoid, omohyoid, sternohyoid), and to the external laryngeal 
muscles (sternothyroid, hyothyroid). Peripheral paralysis of the nerve 
is a rare event. It has been observed as a consequence of wounds and 
tumors or scars. It is indicated by paralysis of the tongue and by dis- 
turbances of the sense of taste and of the act of deglutition. When 
protruded, the tongue is carried toward the paralyzed side by the non- 
paralyzed genioglossus muscle. The paralyzed portion of the organ 
appears wrinkled, and exhibits fibrillary contractions in its muscular 
substance. Chronic cases undergo atrophy of the paralyzed portion. 
Speech, and the act of mastication are affected by glossoplegia. It is 
difficult with the partly paralyzed tongue to convey morsels of food into 
the posterior portion of the mouth and into the pharynx. The articula- 
tion of lingual sounds, e. g., 1, n, s, t, k, g, r, etc., becomes difficult, if 
not impossible. All these disorders are greatly aggravated in bilateral 
paralysis of the tongue. The treatment consists in the application of 
electricity. 

Paralysis of the Radial Nerve — Paralysis Nervi Radialis. 

Etiology. Paralysis of the radial nerve is the most common form 
of paralysis involving the upper extremity. This is due to the long and 
circuitous course of the nerve trunk. Loss of function in the nerve is 
usually excited by injuries or by exposure to cold. It sometimes re- 
sults from rheumatism, or from lead poisoning, and it has been observed 
after various infective diseases. It is frequently paralyzed by com- 
pression of the nerve trunk during sleep. Drunken men not unfrequently 
throw themselves upon a bed, and sleep for hours with the arm doubled 
under the body, or subjected to pressure between the edge of the bed- 
stead and the body ; the nerve is, consequently, bruised and rendered 
incapable of conducting voluntary impulses. The use of crutches, and 
the pressure of heavy burdens upon the arm, not unfrequently occasion 
the disease, and it has been encountered as a consequence of hypodermic 
injections of ether which have probably penetrated the nerve and pro- 
duced inflammation of its tissues. 

Symptoms. Peripheral paralysis of the radial nerve is indicated by 
abolition of the power of motion and sensation in the parts to which 
the branches of the nerve are distributed. The cutaneous distribution 
can be readily learned from the accompanying diagram. (Fig. 149.) 
The muscles that are involved are the extensor triceps, supinator lon- 
gus, supinator brevis, extensor radialis longus et brevis, extensor digitorum 
communis, extensor digit! quinti proprius, ulnaris externus, anconeus, 
abductor pollicis longus, extensor pollicis longus et brevis, extensor 
indicis pro prius. 

When the radial nerve is paralyzed, if the arm be extended horizon- 
tally, the hand is flexed upon the wrist, and is slightly pronated ; the 
fingers are somewhat bent, and the thumb is drawn in under the fore 
and middle fingers ; dorsal extension of the hand and fingers is impos- 
sible, and they cannot be used for any delicate movements like writing. 
The forearm cannot be supinated or extended. 

Paralysis of the common extensor muscle of the fingers prevents 



762 



DISEASES -7 :z: ITER VOUS 5 Y 5 7 I : : 
149. 



2 \ — ! 




I \kdi ■ 



D rqj Pr~otte<il. 
ind distribution of nerves on the superficies. 
- -nth or facial nerve filament supplying the frontal m: 

nth or facial nerve filament supplying the levator labii superioris alaeque nasi. 



DISEASES OF THE PERIPHERAL NERVES. 763 

dorsal flexion of the first phalanges ; and the distal phalanges cannot be 
extended since the interosseous muscles, which are innervated by the 
ulnar nerve, can only operate when the proximal phalanges have been 
previously extended. Firm compression with the hand is, for the same 
reason, impossible, since the flexor muscles can only operate vigorously 
when the extensor muscles can at the same time produce dorsal flexion 
of the hand. 

Paralysis of the radial extensor muscles and of the ulnar extensor 
muscle prevents adduction and abduction of the hand, if at the 
same time the contraction of the flexor muscles of the forearm be in 
any way impeded. 

Paralysis of the extensor muscles of the thumb and of its long abduc- 
tor muscle disqualifies the thumb for all movements of prehension. 

Paralysis of the supinator brevis muscle renders impossible the 
supination of the forearm when the limb is extended. 

When the forearm is placed in a position midway between pronation 
and supination the absence of contraction may be observed in the supi- 
nator muscle when slight pressure is exerted upon the hand during the 
attempt to bend the arm. 

Paralysis of the triceps extensor muscle and of the anconceus quartus 
is indicated by the impossibility of extending the forearm upon the 
elbow-joint. 

Various subjective disturbances of sensation are frequently expe- 
rienced in the paralyzed area, but the degree of actual sensory paral- 
ysis is less than might be expected, since the cutaneous anastomoses are 
so extensive that the skin retains a considerable degree of sensibility 
through the intervention of the branches and terminal fibres of the 
non-paralyzed nerves of the extremity. 

Vasomotor disturbances, and nutritive changes involving the 
joints and the sheaths of the tendons, are sometimes observed. In 
chronic cases the paralyzed muscles may undergo atrophy. 



3. Seventh or facial nerve filament supplying the zygomaticus minor. 

4. Seventh or facial nerve filament supplying the orbicularis oris and quadratus 

menti. 

5. Phrenic nerve supplying the diaphragm. 

6. Musculocutaneous nerve supplying the biceps, brachialis, etc. 

7. Muscuio-cutaneous nerve supplying the brachialis internus. 

8. Ulnar nerve supplying the muscles of forearm and hand. 

9. Radial nerve supplying the flexors of thumb and fingers. 

10. Ulnar nerve supplying the palmaris brevis, abductor digitor. min., opponens 

digitor. min., etc. 

11. Obturator nerve supplying the sartorius, adductor longus, etc. 

12. Crural nerve supplying the adductor longus, vastus internus, etc. 

13. Crural nerve supplying the vastus externus. 

14. Muscuio-cutaneous nerve supplying the flexor digitorum com. long. 

15. Occipital nerve supplying the posterior neck muscles. 

16. Circumflex nerve supplying the triceps, etc. 

17. Intercostal and nerves supplying the lumbar muscles. 

18. Gluteus nerve supplying the adductor magnus, etc. 

19. Popliteal nerve supplying the gastrocnemius externus. 

20. Popliteal nerve supplying the soleus. 



7'34 DISEASES OE THE NERVOUS SYSTEM. 

PROGNOSIS. The duration of radial paralysis is often very consid- 
erable, even after slight injuries. Crutch paralysis generally disappears 
within two weeks, but other forms of the disease frequently require six 
weeks or longer for a cure. 

Treatment. The causes of paralysis must be removed so far as 
they are accessible. Local treatment consists chiefly in the employ- 
ment of electricity. Both varieties of the current may be used with 
advantage. The galvanic current should be applied during the early 
stage of paralysis, while inflammatory conditions are presumably active. 
During later periods of the disease the faradic current affords the best 
results. Strong currents should not be used, and the applications may 
be made every other day for about five minutes at a time. 

Paralysis of the Median Nerve — Paralysis Nervi Mediani. 

Etiology. Less frequently than the radial nerve does the median 
undergo paralysis. It is generally the result of injuries, and it 
is sometimes observed after infective diseases. It seldom results from 
exposure to cold. 

Symptoms and Diagnosis. If the lesion is situated in the lower 
portion of the forearm, paralytic symptoms are restricted to the 
muscles in the ball of the thumb (abductor pollicis brevis. flexor polli- 
cis brevis et opponens). with the exception of the adductor pollicis 
muscle which is innervated by the ulnar nerve. The first and second 
lumbrical muscles are also paralyzed, so that the thumb is useless for all 
delicate manual operations. The phalanges cannot be flexed, and it 
cannot be placed in apposition to the fingers, though by the aid of 
the adductor pollicis muscle it can be placed in apposition with the 
forefinger, and can be drawn backward by the extensor muscles which 
are innervated by the radial nerve, producing an ape-like form of the 
hand. 

When the lesion involves the upper portion of the nerve, the greater 
part of the muscles upon the anterior aspect of the forearm are para- 
lyzed. The second phalanges of the fingers can no longer be flexed, 
because of paralysis of the flexor digitorum sublimis muscle ; and the 
distal phalanges of the second and third fingers cannot be flexed, by 
reason of paralysis of the deep flexor muscle of the fingers. The re- 
maining fingers are flexed by that portion of the deep flexor which is 
innervated by the ulnar nerve, which also innervates the interosseous 
muscles by which the proximal phalanges can still be flexed. The 
second and third phalanges can be extended by the same muscles. 
Hyper-extension of the phalanges, especially in the forefinger, some- 
times exists under these circumstances. Flexion of the hand upon the 
wrist is very imperfect, and is attended by deviation of the hand 
toward the ulnar side of the wrist, in consequence of the contraction of 
the ulnar muscle, which is innervated by the non-paralyzed ulnar nerve. 
Pronation is impossible during extension of the forearm. 

Trophic changes Sire frequently observed in connection with paralysis 
of the median nerve. The fingers appear smooth and glossy, and the 
nails are thickened and deformed : sometimes ulcerations appear in their 



DISEASES OF THE PERIPHERAL NERVES. 765 

vicinity, and there is an increased production of hair upon the skin. 
Atrophy of the muscles follows their disuse. 

Paralysis of the Ulnar Nerve — Paralysis Nervi Ulnaris. 

Symptoms and Diagnosis. Paralysis of the ulnar nerve is produced 
by causes similar to those by which other paralyses are originated. 
The muscles upon the ulnar side of the hand (abductor, flexor brevis, 
and opponens digiti quinti) are incapable of moving the little finger, 
and in consequence of paralysis of the interosseous muscles and the third 
and fourth lumbrical muscles, it can neither be adducted nor abducted. 
Its first phalanx cannot be flexed, and the second and distal phalanges 
cannot be extended. The ulnar portion of the deep flexor muscle of 
the fingers is also paralyzed, so that the phalanges of the two or three 
external fingers are imperfectly flexed. The adductor muscle of the 
thumb is also paralyzed, so that the thumb cannot be placed in apposi- 
tion with the forefinger. In consequence of 'paralysis of the ulnar 
muscle, flexion and adduction of the hand toward the ulnar side of the 
arm becomes impossible. 

Cutaneous sensibility is reduced upon the ulnar side of the palm of 
the hand, and upon the fifth and fourth fingers, and as far as the median 
line of the middle finger. 

Atrophy from disuse follows long-continued paralysis. The ulnar 
side of the hand is wasted, and the interosseous spaces are deeply fur- 
rowed ; sometimes the common extensor muscle of the fingers becomes 
contractured to such an extent that the proximal phalanges of the 
fingers become partially dislocated backward, while the second and 
third phalanges are excessively flexed by the flexor muscles of the 
fingers, producing a peculiar claw-shaped form of the hand. This defor- 
mity is more conspicuous in the fourth and fifth fingers, since the other 
fingers are still innervated by the median nerve 

Paralysis of the Musculocutaneous Nerve. 

Paralysis of this nerve is a very rare incident. When it occurs, the 
muscles by which the forearm is flexed upon the upper arm (biceps 
brachii, coraco-brachialis, brachialis internus) are paralyzed. 

Paralysis of the Axillary Nerve — Paralysis Nervi Axillaris. 

Paralysis of the axillary nerve is generally the result of traumatic 
causes, e. g., dislocation, falls, blows upon the shoulder, crutch paralysis, 
etc. The symptoms have their origin in paralysis of the deltoid muscle. 
The upper arm can no longer be raised to the horizontal position. The 
deltoid muscle after a time undergoes atrophy, and the head of the 
humerus falls partly out of the shoulder-joint. 

Associated Paralyses of the Upper Extremity. 

Lesions involving the brachial plexus may produce associated 
paralyses in the different nerve trunks. The sympathetic nerve may 



766 DISEASES OF THE XERVOUS SYSTEM. 

also be involved at the same time, occasioning contraction of the pupil, 
dilatation of the cutaneous bloodvessels, and narrowing of the palpebral 
fissure upon the injured side. One of the most interesting forms of 
associated nerve paralysis is that which involves the group of muscles 
that are concerned in the act of bringing the hand to the mouth (Erb's 
paralysis), viz., the deltoid, biceps brachii. brachialis internus, supinator 
longus, infraspinatus, supra-spinatus, and supinator brevis muscles. The 
contraction of this group of muscles may be effected by the application 
of a faradic current near the transverse process of the sixth cervical 
vertebra, a little above the clavicle and behind the external border of 
the sterno-cleido-mastoid muscle, where the fifth and sixth nerves 
emerge between the scalenus muscles. 



Paralysis of the Serratus Muscle — Paralysis Musculi Serrati 

Antici. 

Etiology. The serratus muscle is innervated by the long thoracic 
nerve, which, owing to its superficial course, is liable to injury from 
exposure to cold, or violent muscular exertion. Diphtheria and other 
infective diseases are not uncommon causes of its paralysis. 

Symptoms and Di.agxosis. Paralysis of the serratus nerve is 
indicated by modifications in the position of the scapula, which are 
especially conspicuous when the arm is elevated and carried forward. 
While the arm hangs by the side, the inner margin of the scapula 
stands nearer to the spinal column than upon the healthy side, and the 
inferior angle of the bone projects away from the thoracic wall. Some- 
times the margin of the scapula does not lie parallel with the spine. 
in consequence of overaction on the part of the trapezius, rhomboid, 
and levator anguli scapula? muscles, while by the action of the pecto- 
ralis major, biceps, and coracobrachial muscles the inferior angle of the 
scapula is drawn outward away from the back. If the rhomboid and 
levator anguli scapulae muscles are also paralyzed, the deformity is less 
conspicuous. 

The attempt to raise the arm causes the posterior border of the 
shoulder-blade to approach still nearer to the spinal column, while at 
the same time the entire internal surface and inferior angle of the bone 
are projected backward, and stand away from the posterior wall of the 
thorax. The arm also cannot be raised above the horizontal level, 
since the scapula can no longer be sufficiently fixed to afford the neces- 
sary leverage for this movement The simultaneous contraction of the 
rhomboid and levator anguli scapula? muscles renders their form 
distinctly prominent beneath the skin. The movements which are 
necessary in crossing the arms cannot be performed ; and passive 
retraction of the shoulder-blades cannot be resisted by the patient. In 
chronic cases the serratus muscle becomes atrophied, and its serrations 
are no longer visible upon the lateral portion of the thorax. 

Paralysis of the pectoral muscles. The pectoralis major and minor 
muscles are innervated by the anterior thoracic nerve. Their paralysis 
renders adduction of the upper arm difficult, and the hand upon the 
paralyzed side cannot be placed upon the other shoulder. 



DISEASES OF THE PERIPHERAL NERVES. 767 

Paralysis of the rhomboid and levator anguli scapulas muscles. 
Both of these muscles are innervated by the dorsalis scapulae nerve. 
Their paralysis is indicated by the impossibility of approximating the 
posterior border of the scapula to the spinal column, or of raising the 
upper angle of the scapula. 

Paralysis of the latissimus dorsi muscle. This muscle is innervated 
by subscapular branches of the brachial plexus. Its paralysis renders 
it difficult to adduct the upper arm, and to draw the arm and hand 
behind the back. 

Paralysis of the inward rotator muscles of the upper arm (sub- 
scapular and teres major muscles). These muscles are innervated by 
the subscapular nerves. When they are paralyzed the outward rotators 
of the upper arm draw the arm outward and backward, so that the 
palm of the hand is turned forward as the arm hangs by the side 

Paralysis of the outward rotators of the upper arm (infra-spinatus 
and teres minor muscles). The infraspinatus muscle is innervated by 
the suprascapular nerve, and the teres minor muscle is innervated by 
the axillary nerve. Their paralysis renders impossible outward rotation 
of the upper arm ; and as the limb hangs by the side, the ulnar border 
of the hand is turned forward. Movement of the hand across the page 
in writing is very difficult when the infraspinatus muscle is paralyzed. 

Paralysis of the erector spince muscles. When the lower portion 
of these muscles is paralyzed, the lumbar segment of the spinal column 
is projected forward as the patient stands, while the upper portion of 
the body is bent backward, producing the attitude described by the 
term lordosis. In the sitting posture, on the contrary, the lumbar 
region bends backward, producing what is termed kyphosis. The gait 
of the patient resembles that of a waddling duck, and when seated upon 
the floor he can only assume the erect position upon his feet by raising 
himself with the aid of his hands, which are placed at first upon the 
knees, so as to support the shoulders, and are then alternately slipped 
up along the thighs as he rises to the erect position — thus apparently 
climbing up his own limbs. 

When the upper segment of the erector spinse muscles is paralyzed, 
the thoracic portion of the spinal column bends one way or the other, 
according to the extent and location of the paralysis, producing kyphosis 
when the upper portion of the thorax is bent forward, or scoliosis when 
it is bent laterally. Paralysis of the cervical portion of the muscles 
renders it impossible to support the head. 

Paralysis of the abdominal muscles seldom occurs. When it is 
unilateral, the navel is drawn during the act of respiration toward the 
healthy side. Bilateral paralysis renders it difficult or impossible to 
cough, sneeze, or perform any other movement connected with expira- 
tion or with the expulsion of the abdominal contents. (Fig. 150.) 

Paralysis of the diaphragm may result from inflammatory processes 
within the thorax or abdominal cavity, and it may be produced by 
pressure of a tumor upon the phrenic nerve. It is sometimes observed 
after diphtheria or after lead poisoning. It is indicated by retraction 
of the epigastrium and hypochondria during inspiration, and by 
their protrusion during expiration — the reverse of normal conditions. 



768 



DISEASES OF THE NERVOUS SYSTEM. 



Respiration is thus rendered difficult and laborious. The disease is 
always attended with great danger. 



Fig. 150. 





Rectus abdo- 
minis (nervi 
intercostales 
abdominis) 



Wk 



Serratus mag- 
nus 

Latissimus 
dorsi 



Obliquus ab- 
dom. ext. 
i (nervi inter- 
mm V cost, abdom.) 




Transversalis 
abdom. 



Thoracic and abdominal motor nerve points. (Bristowe.) 



Peripheral Paralysis of the Nerves of the Lower Extremities. 

Paralysis of the loiver extremities is usually dependent upon spinal 
or cerebral diseases. Peripheral paralysis of their nerves is a rare 
event, and is generally produced by diseases, or tumors, or hemorrhages 
that press upon the origins of the nerves near their points of emergence 
from the spinal column. It may also be produced by tumors in the 
pelvis, or by injuries, or by the neuritic inflammations which sometimes 
follow acute infective diseases. The results and treatment of paralysis 
involving the lower extremities are identical with what have been already 
described in connection with the upper extremities. Space will only 
permit a rapid review of the prominent symptoms that are presented by 
the affection of particular nerves and muscles. *^SJ5 

Paralysis of the crural nerve is indicated by the impossibility of 
contracting the psoas, pectineus, sartorius, and quadriceps muscles. 
This renders it impossible to bend the thigh upward against the abdo- 
men, or to extend the leg when it is bent against the thigh. Walking 
and rising from the sitting position are, therefore, impossible. 

Paralysis of the obturator nerve affects the adductor muscles, the 
obturator externus, gracilis, and, in part also, the pectineus muscles. 
Adduction of the thigh is, therefore, impossible. The paralyzed thigh 



SPASM OF THE MOTOR NERVES. 769 

cannot be crossed over the other ; and when lying down, the body can- 
not be turned over from the back upon the belly. External rotation 
of the thigh is also rendered difficult. 

Paralysis of the glutceal nerves involves the glutseal muscles, the 
obturator internus, pyriform, and extensor fasciae latse muscles. Ro- 
tation of the thigh in either direction, and its abduction are rendered 
difficult. It is impossible to raise the body from the sitting to the erect 
position. Walking, and ascending a flight of stairs are, therefore, very 
difficult. 

Paralysis of the sciatic nerve is the most common variety of paral- 
ysis in the lower extremities. The disease sometimes attacks the entire 
nerve and all its branches, but frequently it is limited to certain portions 
of the nervous distribution. Paralysis of the peroneal branch is the 
most frequent form. The muscles upon the posterior surface of the 
thigh are not often paralyzed. When rendered incapable of function, 
rotation and adduction of the thigh are hindered and the leg cannot be 
drawn up against the posterior aspect of the thigh. 

Paralysis of the peroneal nerve affects the peroneal muscles, the ex- 
tensor muscles upon the anterior aspect of the leg, and the anterior 
tibial muscle. The foot assumes the varo-equinus position. 

Paralysis of the tibial nerve causes paralysis of all the muscles in 
the calf of the leg, and the flexor, adductor, abductor, interosseous, and 
lumbrical muscles in the sole of the foot. Plantar flexion of the foot is 
rendered impossible, and the toes can neither be adducted nor abducted. 
By the extensor muscles upon the anterior portion of the leg the foot is 
dorsally flexed, and the extremity rests upon the heel and inner border 
of the foot (pes valgo- calcaneus). 



CHAPTER II. 

SPASM OF THE MOTOE NERVES. 

Spasm of the Facial Nerve. 

Spasms involving the muscles that are innervated by the facial nerve 
are generally of a clonic character. They may affect all of the facial 
nerves, or they may be limited to groups, or to single muscles. 

Etiology. Facial spasm is more frequent in advanced life than 
among children. It is more commonly observed among patients who 
belong to neurotic and weakly families, in which hysteria, epilepsy, and 
other nervous disorders are common. It frequently results from chloro- 
sis, from exposure to cold, from injuries or diseases of the skull, or 
from intra-cranial tumors which irritate the facial nerve. 

Facial spasm may be excited as a reflex consequence of painful 
affections involving the trigeminal nerve, or the nerves of the abdomi- 
nal and pelvic organs ; in this way it may sometimes result from the 
presence of intestinal parasites. 

49 



770 DISEASES OF THE NERVOUS SYSTEM. 

Facial spasm sometimes arises as a habit acquired by imitation. In 
many cases, however, no apparent cause for the disease can be dis- 
covered. 

Symptoms. Facial spasm is indicated by the occurrence of involun- 
tary contraction on the part of the facial muscles, by which a very 
great variety of facial distortions and grimaces can be produced. 
Usually only one side of the countenance is affected. The visage is 
contorted without the knowledge of the patient, though the disorder 
may be aggravated by mental or physical excitement. Spasmodic- 
movements generally cease during the night, though sometimes they 
occur during sleep. 

Secretion and the sensation of taste are not affected. The electrical 
reactions of the muscles and nerves remain unchanged. In many 
instances pressure points may be discovered in connection with the 
disease, that is, certain points in the course of the sensory nerves are 
very sensitive to pressure. Compression of the tissues with the finger 
at these points is frequently followed by the cessation of the spasm, 
though occasionally it may be excited or aggravated by such pressure. 
These points may sometimes be discovered over the supra-orbital or 
infra-orbital nerves, or upon the mucous membrane of the nasal 
and oral cavities. Sometimes they may be found upon the transverse 
or spinous processes of the vertebrse, or upon the sternum, or in the 
intercostal spaces, or on the wrist. 

Facial spasm is not attended with pain, unless it be associated with 
neuralgia of the trigeminal nerve. In certain severe cases, other 
muscles besides those in the territory of the facial nerve become involved 
in the paroxysms of spasm. 

Prognosis. The disease is never dangerous, but is usually obsti- 
nate, and sometimes continues during the whole course of life. 

Treatment. In every case careful search should be made for 
causes of reflex irritation or local injury of the nerve. Carious teeth 
sometimes furnish the point of departure for serious disorders of this 
kind. Nervous, anaemic, and chlorotic patients must be invigorated 
by general hygienic, restorative, and tonic treatment. Large doses of 
the fluid extract of conium are sometimes beneficial. Rheumatic sub- 
jects require the use of salicylic acid, hot baths, and counter-irritation. 
When pressure points can be discovered, galvanic electricity is of great 
service ; the anode should be placed upon the painful point, while the 
cathode rests upon the back of the neck, or upon the sternum or any 
other indifferent point. Weak currents should be used, and the time 
occupied by each session should not exceed five minutes. In certain 
cases, benefit has been derived from hypodermic injections of morphine 
and atropine, or of strychnine. Refrigeration with the spray of rhigo- 
lene along the branches of the nerve, has been occasionally employed 
with success. Surgical treatment by stretching the nerve affords only 
temporary relief. Nerve section merely substitutes one disease for 
another. 

Tonic muscular spasm sometimes follows paralysis of the facial 
nerve, and is occasionally developed as an independent disease. It 



SPASM OF THE MOTOR NERVES. 771 

should be treated by the use of galvanic currents upon the paralyzed 
side, and faradic currents upon the healthy side. 

Spasm of the orbicular muscle of the eyelids may be either tonic 
(Blepharospasm), or clonic (Nictitation). Both forms of the disease 
are generally dependent upon diseases of the eye, by which reflex 
spasm is produced. It is also frequently associated with trigeminal 
neuralgia, and with diseases of the nasal and oral cavity, including the 
teeth. Pressure points can be frequently discovered, and it is astonish- 
ing to see how quickly the spasmodic closure of the eyelids is some- 
times arrested when the finger is brought to bear upon some particularly 
sensitive spot. Clonic spasm of the eyelid occurs more frequently 
than the tonic form, and among many persons it appears more like a 
habit than a disease. 

The treatment of these affections is the same as that which has been 
prescribed for facial spasm. 

Spasm of the Muscles of Mastication. 

Spasm of the muscles which are innervated by the motor portion 
of the trigeminal nerve may be either tonic or clonic. This last variety 
of the disorder most commonly occurs as a result of exposure to severe 
cold (chattering teeth). Tonic spasms are generally dependent upon 
traumatic causes, or tumors involving the trigeminal nerve. It may be 
observed in connection with trigeminal neuralgia, or with diseases in- 
volving the teeth, or after operations upon the mouth. It is sometimes 
observed among children as a consequence of parasites in the intestinal 
canal. The temporal and masseter muscles are contracted and resistant ; 
the mouth cannot be opened ; it is difficult or impossible to speak or to 
take nourishment. The condition may be differentiated from ankylosis 
of the articulation of the lower jaw by the firmness and tension of the 
contracted muscles. Under the influence of anaesthetics spasm yields, 
while ankylosis remains permanent. Treatment consists in the re- 
moval of exciting causes ; the hypodermic injection of morphine, and 
the use of chloroform in severe cases. The galvanic current may be 
applied with progressively increasing and diminishing strength trans- 
versly through the masseter muscles. 

Hypoglossal spasm. Hypoglossal spasm usually assumes the clonic 
form. It sometimes involves the tongue only in connection with move- 
ments of mastication ; in other cases, it appears only during the act of 
articulation. It is frequently associated with spasmodic or neuralgic 
conditions of other nerves and muscles. 

Accessory nerve spasm. Accessory nerve spasm involves the 
sterno-cleido-mastoid and trapezius muscles. It may be either tonic, 
clonic, unilateral, or bilateral. It is frequently excited by exposure to 
cold, or by injuries or diseases of the cervical vertebrae, or by infective 
diseases, or as a reflex consequence of teething, worms, abdominal and 
uterine diseases, especially when occurring among nervous and excitable 



772 



DISEASES OF THE NERVOUS SYSTEM. 



patients who belong to neurotic families. When unilateral, clonic 
spasm invades the sterno-cleido-mastoid muscle, the face and chin are 
jerked over the opposite shoulder at each recurrence of the spasm. If 



Fig. 151. 



/y 


^0$r 






/#n\ 




• 


\ 


H 


kmi 


• i \ 


V' 


\ 






1 \ 

ft* 


" 


\\ 

x 



Upright spinal extension frame. Posterior 
curved position. (Stillman.) 



Fig. 152. 




Upright spinal extension frame. Anterior 
curved position. (Stillmax ) 



Fig. 153. 




Recumbent spinal extension frame. Posterior curved position. (Stillman. 

Fig. 154. 




Recumbent spinal extension frame. Anterior curved position. (Stillman.) 

the trapezius muscle is simultaneously affected, the head is at the same 
time drawn backward and outward, toward the affected shoulder. 
Sometimes the spasms alternate between the two muscles. "When both 
the sterno-cleido-mastoid and trapezius muscles are simultaneously in- 



SPASM OF THE MOTOR NERVES. 773 

volved, the head is jerked now one way, and then the other, or back- 
ward and forward (Salaam spasm) ; this last form of the disease is 
almost exclusively observed among children. 

Like other forms of spasm, accessory nerve spasm is liable to be 
aggravated by mental or physical excitement ; and other groups of 
muscles are sometimes associated in the spasmodic movement. The 
disease is extremely obstinate, and may continue for a lifetime. 

Tonic spasm of the sterno-cleido-mastoid and trapezius muscles oc- 
casions a permanent displacement of the head, according to the pre- 
dominance of tension upon one side or other of the neck. The 
prognosis is generally unfavorable. Treatment must consist in the 
effort to discover and remove the causes of irritation, and in the use of 
electricity and narcotics, as prescribed in cases of facial spasm. Great 
benefit is sometimes obtained from orthopaedic treatment and stretching 
of the spinal column, according to the methods described by Stillman 
and other orthopaedic surgeons. (Figs. 151, 152, 153, 154.) Resection 
of the accessory nerve and myotomy are useless. 

Spasm of the muscles in the neck, shoulder, and arm. These 
muscles, which are innervated from the cervical and brachial plexus, 
may be invaded by tonic or clonic spasms. The contractions may be 
either unilateral or bilateral, and may invade only one muscle, or many 
groups of muscles. The causes and treatment are the same that have 
been already described in connection with other forms of spasm. 

Spasm of the splenius capitis muscle draws the head backward, 
but at the same time turns the face and the chin toward the affected 
side. The contracted muscle may be felt under the anterior margin of 
the trapezius muscle, and the sterno cleido-mastoid is relaxed upon the 
same side, though tense upon the opposite side. 

Spasm of the rhomboid muscle is occasionally observed as a tonic 
contraction of the muscle by which the inferior angle of the shoulder- 
blade is drawn up toward the spinal column. 

Spasm of the levator anguli scapulae muscle causes the upper 
angle of the scapula to be drawn upward, while the head is slightly 
drawn backward. 

Spasm of the diaphragm, when it assumes the clonic form, is the 
occasion of hiccough or singultus. This respiratory disorder is pro- 
duced by spasmodic contraction of the diaphragm, which occasions a 
sudden and violent inspiration that is abruptly terminated by spasmodic 
closure of the glottis. These successive interruptions may follow one 
another with such rapidity as to occasion dyspnoea and distress in the 
epigastric region. The disorder is usually observed among young chil- 
dren as a consequence of excessive eating or drinking, especially when 
associated with nervous excitement. It may, however, be produced by 
inflammatory diseases or tumors within the thoracic, abdominal, or pelvic 
cavities. It sometimes occurs among nervous patients who have been 
exhausted by severe and chronic diseases or wasting discharges. 



774 DISEASES OF THE NERVOUS SYSTEM. 

The treatment of hiccough requires attention to its underlying causes. 
Ordinary paroxysms may be relieved by drinking cold water, or by the 
use of aromatic stimulants. Various domestic remedies, like pepper- 
mint, paregoric, laxatives, etc., usually give relief. In severe cases it 
may be necessary to have recourse to hypodermic injections of morphine 
and atropine. Large doses of bromide of potassium are sometimes 
beneficial. The application of mustard to the epigastrium, and local 
applications of faradic or galvanic currents are of great service. 

Tonic spasm of the diaphragm as a peripheral disease is usually 

dependent upon exposure to cold and rheumatic causes. When it 

occurs as a result of central nervous disease, it is a very dangerous 
affection, and may terminate fatally. 

Spasm of the muscles in the lower extremities participates in the 
characteristics of other forms of muscular spasm. A special form of 
the disease, popularly described as cramp in the legs, is sometimes ob- 
served after severe muscular exertion. It not unfrequently attacks 
swimmers, as a consequence of violent efforts in the water. It is one of 
the most painful symptoms of Asiatic cholera, in which disease it is 
dependent upon disorders of metabolism in the tissues. It has also 
been observed in cases of diabetes, and in connection with disorders of 
the circulation, especially among pregnant women and patients who 
suffer with varicose veins. 

Cramp may be frequently relieved by hyper-extension of the affected 
muscles. Not unfrequently, however, it is necessary to employ hypo- 
dermic injections of morphine and atropine, together with the external 
use of friction and chloroform liniment. 



CHAPTER III. 

DISEASES OF THE SENSORY NERVES. 



NEURALGIA. 

Trigeminal Neuralgia — Neuralgia Nervi Trigemini. 

Etiology. Trigeminal neuralgia is the most common of neuralgic 
diseases. It is most frequently observed among women between the 
twentieth and fiftieth years of life, yet it is not uncommon among old 
people during the period of involution. Poverty, exposure to cold, and 
damp weather, are fruitful causes of the disease. 

The special causes of trigeminal neuralgia are fivefold. They 
may be either constitutional, infective, toxic, local, or reflex. 



DISEASES OF THE SENSORY NERVES. 775 

Among the constitutional causes may be enumerated the influence of 
heredity ; venereal excesses ; extraordinary physical or mental exer- 
tion, especially when associated with care and sorrow; anaemia; 
chlorosis ; severe and wasting discharges ; frequent childbearing ; 
prolonged lactation ; and a predisposition to arthritic disorders. 

Among infective causes of trigeminal neuralgia, malaria stands first. 
Intermittent supra-orbital neuralgia is the usual form of the disease 
when dependent upon this cause. Syphilis and rheumatism take a 
subordinate place as causes of the disease. 

The toxic form of trigeminal neuralgia is usually dependent upon 
lead and mercurial poisoning. 

Local causes of trigeminal neuralgia are generally the result of ex- 
posure to cold and damp, or to injuries which involve the territory of 
the trigeminal nerve. The eruption of wisdom teeth, and compression 
of the alveolar nerves by contracting tissues in the toothless jaws of old 
people, are not uncommon causes of the disease. It is also sometimes 
excited by diseases of the ears, or by inflammation of the supra-orbital 
spaces. In certain cases it is excited by over- exertion of the ocular 
muscles, especially when associated with astigmatism or other defects of 
the eyes. In other cases the disease is dependent upon inflammatory 
conditions, or upon tumors which involve the trunk and principal 
branches of the nerve during their passage through the bony canals of 
the skull and facial bones. 

The reflex forms of trigeminal neuralgia are usually dependent upon 
abdominal or pelvic disorders. Sometimes they are the result of 
injuries that involve other nerves of the body. 

Pathological Anatomy. In many cases of trigeminal neuralgia 
it is impossible to discover any pathological changes in the nerve ; but 
sometimes inflammatory changes, proliferation of connective tissue in 
the sheath of the nerve, and various forms of local degeneration have 
been discovered, involving the nerve fibres or the ganglionic cells in 
the ganglion of Gasser. 

Symptoms. Trigeminal neuralgia is almost always unilateral, and 
most frequently invades the ophthalmic division of the nerve, producing 
supra-orbital neuralgia. The second division stands next in order, 
while the third division is least exposed to painful affections. 

An attack of trigeminal neuralgia usually occurs in paroxysms which 
sometimes originate suddenly, but are frequently preceded by sensations 
of creeping or prickling in the skin. When fully developed, the pain 
assumes a terrific, boring, or burning, or lancinating character which 
sometimes appears to be wholly superficial, but in other cases is referred 
to the deeper portions of the face and head. The duration of the 
paroxsyms is sometimes very brief, occupying only a few seconds, but 
they are frequently repeated, usually at regular intervals of a few min- 
utes at the longest. Sometimes the attack begins with chills, and is 
accompanied by perspiration, like the paroxysm of intermittent fever. 
Frequently an attack will commence without any apparent cause ; in 
other instances it is induced by slight exposure to a draught of cold air, 
or by any physical or mental form of excitement. 

Attacks occur more frequently during the day than by night. In 



776 DISEASES OF THE XERVOUS SYSTEM. 

many cases the intervals are free from pain, and are characterized by 
apparently good health. In certain cases, however, the attacks are so 
frequent that the patient complains of almost constant suffering, and 
exhibits signs of considerable exhaustion. 

In a large proportion of cases pressure points may be discovered 
along the course of the nerve branches, especially over the foramina 
through which they emerge from their bony canals, or even upon dis- 
tant portions of the body, chiefly along the spinous or transverse pro- 
cesses of the vertebrae. 

In many instances vasomotor and secretory disturbances are mani- 
fested in the territory occupied by the trigeminal nerve ; the skin is 
reddened, exhibits elevation of temperature, and is covered with perspi- 
ration ; the bloodvessels dilate, and the arteries pulsate ; the con- 
junctivae are injected, tears flow freely ; the mucous membrane of the 
nose and of the mouth secretes inordinately. 

Trophic changes are frequently observed. Aphthous ulcerations 
and hemorrhagic extravasations sometimes take place within the mouth. 
Herpes and other cutaneous eruptions may appear about the lips or 
along the course of the affected nerve branches. The hair frequently 
turns grav, sometimes recovering its natural color after the termination 
of an attack. Iritis, choroiditis, glaucoma, and neuro-paralytic ophthal- 
mia have been observed. The tactile sensibility of the skin seldom 
manifests any considerable alteration. The sense of taste is frequently 
disordered, and sometimes the sense of hearing is temporarily affected 
during an attack. 

Spasmodic contractions of the facial muscles frequently accompany 
the paroxysms of neuralgia. Sometimes the muscles of the extremities 
are also involved in the spasmodic process. 

Prognosis. The prognosis is dependent upon the causes of the 
disease, which may continue, accordingly, during a very variable 
period of time. The disease is frequently chronic, and is liable to re- 
lapses after apparent recovery. 

Treatment. The treatment should include a careful search for, and 
removal of, the causes of the disease. When it is dependent upon 
malaria, it may be soon relieved by large doses of quinine or arsenic. 
When dependent upon exposure to cold and rheumatism, salicylic acid 
should be freely administered. Syphilitic cases require the use of iodide 
of potassium and mercurials. Constipation must always be prevented: 
and morbid conditions of the blood require appropriate treatment. In 
many instances the disease is relieved by proper care of the teeth, or by 
the cure of disorders in the nasal passages. In certain cases which do 
not appear to depend upon any discoverable cause, the attacks of pain 
may be arrested by the administration of drachm doses of quinine. 
Hypodermic injections of morphine and atropine are useful, but this 
method of treatment should never be intrusted to the patient, since in 
the majority of cases the opium habit soon becomes established. The 
application of electricity in the form of a galvanic current sometimes 
affords temporary relief. The painful region should be included be- 
tween the two poles of the apparatus, the anode being placed over the 
seat of pain : the current should be used for five minutes, several times 



DISEASES OF THE SENSORY NERVES. 777 

a day. Veratrine ointment, cups, blisters, and chloroform liniment, 
sometimes give relief. For internal use, in rheumatic cases, may be 
recommended crystallized aconitine in doses of -^ihr °f a g ram every 
two hours, until the peculiar tingling sensation produced by aconite is 
recognized. Tincture of colchicum and tincture of aconite may be 
given three times a day. 

Be. — Tr. aconit. rad 3j. 

Tr. colchici §ij.— M. 

S. — Ten drops three times a day. 

Large doses of antipyrine, acetanilide, or phenacetine, may be given 
three or four times a day. Iodide of potassium is sometimes useful in 
doses of five or ten grains three times a day. The nerve tonics are 
frequently useful, viz. : nitrate of silver, chloride of gold and sodium, 
carbonate of iron, phosphide of zinc, and nux vomica. Strychnine is 
sometimes beneficial when given in doses of y 1 ^ of a grain every four 
hours. Chloral hydrate and butylchloral are also beneficial ; and the 
tincture of gelsemium, in doses of five to twenty drops three times a 
day, is highly recommended by many. 

When the disease appears obstinate ^nd will not yield to these 
measures, surgical interference becomes necessary. Stretching or sec- 
tion of the affected nerve gives only temporary relief. Thorough ex- 
section of the affected portion of the nerve is attended by favorable 
results in many cases. 

Occipital Neuralgia — Neuralgia Cervico-Occipitalis. 

Occipital neuralgia is excited by the same causes that produce tri- 
geminal neuralgia. It is characterized by painful paroxysms which 
originate in the upper part of the post-cervical region and follow the 
tracks of the nerves as far as the inter-parietal line over the top of the 
head. Sometimes the trigeminal nerve branches are at the same time 
involved, and the pain may irradiate into territories that are occupied 
by other nerves. 

Pressure points are found between the mastoid process and the first 
cervical vertebra where the occipital nerve approaches the surface. 
Another point may be found upon the parietal prominence. Others 
exist along the spinous process of the cervical vertebrae. The scalp is 
usually in a condition of hyperesthesia, so that contact with the hair 
excites paroxysms of pain. 

Vasomotor disturbances are exhibited on the part of the sympathetic 
nerve fibres, frequently producing changes in the diameter of the pupils, 
and dilatation of the blood vessels in the affected ear and side of the 
face ; the conjunctivae are injected, tears are secreted in excess, and 
the skin of the face feels warmer than natural. Subjective disturb- 
ances of hearing sometimes occur. Trophic changes are rarely ob- 
served. In rheumatic cases the cervical lymph glands frequently swell. 
In certain cases muscular spasms are developed, and severe vomiting 
sometimes accompanies an attack. 

The duration of the disease is variable. In certain cases recovery 



77^ DISEASES OF THE NERVOUS 3 Y SI 

never takes place, though this is less common than in trigeminal neur- 
algia. 

The treatment must be conducted in accordance with the rules laid 
ii for the treatment of trigeminal and other forms of neuralgia. 

Phrenic neuralgia. P is characterized by par- 

oxysmal pain in the lower part of the thorax and along the whole 
course of the phrenic nerves. It may be either unilateral or bilateral. 
Painful sensations frequently irradiate into the neck, shoulders, and 
arms. Pressure points exist along the insertion of the diaphragm, and 
upon the spinous processes of the cervical vertebra?, and in the lateral 
::' the neck. The movements of respiration are frequently 
subjected :: great disturbance, and the act of swallowing is attended 
with great difficulty. The disease is frequently difficult of recognition, 
since it may be easily confounded with angina [ r with pleural 

and peritoneal diseases. 

Cervico-brachial neuralgia is almost always unilateral. It may 
involve only a single nerve, or an extensive group of nerves. Motor 
disturbances are frequently associated with the sensory disorder, since 
the nerves of the extremities contain both motor and sensory fib". 

Pain constitutes the principal symptom. It is especially severe after 

mot wounds of the nerves. It usually occurs in paroxysms which 

are aggravated by movement and by the warmth of the bed at night. 

Partial relief is frequently obtained by carrying the arm in a sling. 

: not appear with any degree of regularity. I' 
motor disturbances are very commonly observed, and consist either in 
pallor and coldness of the skin (vasomotor spasm), or in an increas 
redness and temperature (vasomotor paralysis . Sometimes there is 
copious perspiration. T . . > n appear in the form of herpes 
:. urticaria, eczema, pemphigus, increased growth of hair, thick- 
ening and incurvation of the nails, glossy fingers, etc. Mut 

fibrillar contractions, and paralysis are sometimes observed. 
The hand sometimes assumes the form of a claw, and in man;. - - 
becomes impossible to perform acts of precision, like writing, sew _ 
playing on musical instruments, etc. The duration of the disease de- 
pends upon its causes, which in certain cases are irremediable. 

Intercostal neuralgia may involve any one or all of the dorsal 

is usually manifested in the intercostal division of the 

nerves, though in certain cases the dorsal division participates in the 

disea- jee the painful territory may extend from the neck 

•f the ilium and the symphysis pubis. The d> - 

ited by causes similar to those that have been already enumerated 

unection with trigeminal neuralgia. It is frequently associated 

with - i, and it is frequently caus-. 

that proceed from the 74ns. 

It often occurs during the period of convalescence get. 

and it is almost always se ited with the eruption of s . 

The painful symptoms of intercostal neuralgia are generally unilateral, 



DISEASES OP 1 THE SENSORY NERVES. 779 

and they are frequently accompanied by irradiations of pain into the 
territory of other nerves. The left side of the body is most frequently 
affected, in consequence of the more circuitous course of the blood 
which, on that side, finds its way into the hemiazygos vein before reach- 
ing the vena cava. Venous congestion of the nerves may, therefore, 
be more easily produced by slight disturbances in that region than upon 
the opposite side. Intercostal neuralgia occurs in the form of painful 
paroxysms which may be aroused by muscular exertion of every kind. 
Sometimes the slightest movement or contact is sufficient to excite an 
attack. Pressure points may be frequently discovered in three sepa- 
rate localities which are associated with each nerve ; over the point of 
emergence of the dorsal branch near the spinous process of the corre- 
sponding vertebra ; over the point of emergence of the lateral branch 
of the nerve in the axillary line ; and at the terminal extremity of the 
nerve near the border of the sternum. 

In many instances the skin in the neighborhood of the affected nerve 
is hyperaesthetic. Occasionally the opposite condition of anaesthesia is 
manifested. Herpes zoster is frequently developed in connection with 
intercostal neuralgia. 

Intercostal neuralgia may be differentiated from rheumatism of the 
intercostal muscles by the fact that they are not particularly sensitive 
to pressure, and that the pain is paroxysmal, while the opposite condi- 
tions of sensitiveness to pressure and persistence of pain are character- 
istics of rheumatism. 

Pleurisy is marked by other concurrent symptoms of disease within 
the thorax. Periostitis of the ribs is accompanied by local swelling 
upon the costal surfaces. Gastralgia is indicated by concomitant dis- 
orders of the stomach. 

Mammary neuralgia (mastodynia) is an intercostal neuralgia that 
invades the mammary gland. It is generally encountered in the female 
sex during the first fifteen years of adult life. It may be caused by 
any of the ordinary antecedents of neuralgia, and it is frequently 
observed as a consequence of prolonged lactation, or disturbance of 
menstruation. In many instances indurated masses can be felt in the 
substance of the gland during the paroxysms of pain. Their exact 
nature is not clearly understood. 

Lumbo-abdominal neuralgia has its seat in the course of the four 
first lumbar nerves (ilio-hypogastric, ilio-inguinal, lumbo-inguinal, and 
external spermatic.) Painful paroxysms are experienced in the loins, 
hips, lower portion of the abdomen, and groin. Pressure points may 
be discovered near the spine, upon the crest of the ilium, and above the 
groin. Contraction of the cremaster muscle frequently occurs, and the 
vesical and vaginal discharges are increased. 

Crural neuralgia follows the course of the crural and saphenous 
nerves, along the anterior and inner surfaces of the thigh and leg to the 
inner border of the foot and the great toe. Pain is increased by walk- 
ing and by other movements of the leg. It is frequently aggravated at 



780 DISEASES OF THE NERVOUS SYSTEM. 

night. Hyperesthesia of the skin, vasomotor disturbances, and trophic 
changes are not uncommon. Occasionally anaesthesia is developed, or 
the patient may complain of paresthetic sensations. 

Obturator neuralgia owes its principal importance to the fact that it 
rarely occurs excepting as a symptom of hernia in the obturator fora- 
men. Pain is then experienced along the inner surface of the thigh as 
far as the knee, and is connected with numbness, formication, and 
impossibility of adducting the thigh. 

Sciatica — Neuralgia Ischiadica. 

Etiology. Sciatic neuralgia is a very common disease. It occurs 
more frequently among men than among women, between the twentieth 
and sixtieth years of life. It is dependent upon the ordinary causes of 
neuralgia, and is especially common as a consequence of exposure to 
wet and cold. It is frequently originated by injuries and diseases of all 
kinds that involve the lower portion of the spinal column, the pelvis, 
and the pelvic organs. It is sometimes associated with gout, diabetes, 
scurvy, purpura, etc. ; and it is often encountered as a consequence of 
central diseases involving the spinal cord. It may follow any of the 
infective diseases, including those of malarial, syphilitic, and gonor- 
rhoea! origin. 

Pathological Anatomy. Sciatica of a purely neurotic character 
presents no visible changes in the structure of the nerve, but neurotic 
forms of the disease exhibit all the appearances which characterize in- 
flammation of a nerve. Compression by a neighboring tumor is followed 
by atrophy of the nerve. 

Symptoms. Sciatica usually occurs as a unilateral disease. It may 
involve the whole territory of the nerve, or it may be restricted within 
a limited portion of its distribution. When thus limited, it generally 
occupies the posterior cutaneous branch, or, in certain cases, the plantar 
region of the foot. 

The pain of sciatica is constant, although it may exhibit paroxysms of 
increased severity which are aggravated by movements of the limb and 
body, and are worse at night than during the daytime. 

Occasionally pain is diminished by walking or bearing the weight of 
the body upon the affected limb. In many cases other nerves become 
simultaneously involved in the neuralgic paroxysms, and vomiting 
occurs when the stomach is reached by such wide-spreading distress. 
Muscular spasms in the affected limb are not uncommon. Pressure 
points are not commonly developed, though the whole course of the 
nerve itself is frequently sensitive to pressure. 

In neurotic forms of the disease the electrical reactions remain 
unchanged, but in neuritic cases the reaction of degeneration is devel- 
oped. Vasomotor and trophic disturbances are occasionally observed, 
and the muscles of the limb are frequently wasted from disuse, or as a 
consequence of neuritis. In many instances modifications of sensi- 
bility involve the sensory nerves of the limb. The patellar reflex 
remains unchanged. 



DISEASES OF THE SENSORY NERVES. 781 

The patient is frequently compelled to bend the knee and to draw 
up the thigh, so as to relax the muscles and tissues of the limb, and 
often he is forced to lie motionless, with the back bent forward and the 
limbs drawn up to the body, in order to prevent the incidence of agon- 
izing paroxysms of pain. It is often impossible to sit up, or to assume 
the erect position, much less to walk about. Constipation frequently 
occurs, and always aggravates the disease. Sugar is often present in 
the urine. 

Diagnosis. Sciatica must be differentiated from coxitis and from 
psoitis, which are characterized by a peculiar position of the limb, and 
by pain on rotation of the thigh, or pressure of the head of the femur 
against its socket. In muscular rheumatism the muscles are par- 
ticularly painful on pressure. Hysterical pains must be differentiated 
by attention to the general condition and symptoms of the patient. 

Prognosis. The prognosis depends upon the nature of the causes. 
Sciatica is often a very chronic disease. It gradually develops, persists 
for a time, and then slowly subsides. Relapses are frequent. 

Treatment. Every case of sciatica requires treatment in accord- 
ance with its underlying cause. Repose and warmth, together with a 
soluble state of the bowels, must be secured. Great relief is often ob- 
tained by wrapping the entire limb with cotton-wool, which is then 
covered with a sheath of oiled silk or rubber cloth. The limb should 
be rubbed every morning with turpentine or chloroform liniment. Iodide 
of potassium should be administered in five- or ten-grain doses three 
times a day. In recent cases pain is sometimes aggravated by the em- 
ployment of electricity, but chronic cases are greatly benefited by its 
use. The galvanic current should be employed with the aid of unusu- 
ally large electrodes. The faradic brush sometimes affords relief. 
Great benefit is afforded by the use of hot baths, at the Hot Springs of 
Arkansas, or the brine baths at Mt. Clemens, in Michigan. 

The remedies which have already been recommended in the treat- 
ment of trigeminal neuralgia are useful in cases of sciatica. When 
pressure can be endured, daily massage is very beneficial. Obstinate 
cases may be treated by nerve-stretching, an operation which can be 
performed, with at least temporary relief, by forcibly flexing the thigh 
against the abdomen, while the leg is firmly held in the position of ex- 
tension. It is sometimes necessary to render the limb motionless by 
the application of a thigh splint, as if treating a fracture of the femur. 

Spermatic neuralgia involves the spermatic nerve and invades the 
testis, which becomes sensitive to pressure, and is sometimes tumefied. 
The paroxysms of pain are often attended with great agony, but may 
be distinguished from renal colic by their location and by the healthy 
quality of the urine. The disease is usually encountered among pale 
and nervous young people who have exhausted themselves by venereal 
excesses. It may also occur as a consequence of varicocele, or as a 
symptom of hysteria. The other causes of neuralgia may frequently 
be discovered. Similar pain may be often encountered in other neigh- 
boring nerves, invading the bladder, the perineum, and the rectum. 



752 DISEASES OF THE NERVOUS SYSTEM. 

Coccygodynia is characterized by severe pain in the coccyx, and is 
increased by pressure of any kind and by movement of the body. It 
generally occurs among women, and is probably dependent, in the ma- 
jority of cases, upon organic disease of the bone itself. It generally 
becomes necessary to cut the bone free from its connections with the 
neighboring parts, or to remove it altogether. 

Neuralgia of the joints is usually observed among neuralgic women, 
and is dependent upon the ordinary causes of neuralgia and hysteria. 
It is characterized by paroxysms of pain which cannot be referred to 
any local changes in the affected joints. The hip and knee joints are 
the favorite seats of the disease, though the small joints are sometimes 
involved. During the occurrence of a paroxysm the painful joint 
exhibits redness, heat, and swelling, which immediately disappear with 
the cessation of pain. Slight contact with the skin is more distressing 
than firm pressure. Sometimes muscular spasms occur ; and during 
a painful paroxysm the affected limb is held in a position of extension, 
instead of being flexed, as in inflammatory diseases of the joints. 
Pressure points about the joints can usually be discovered, as in other 
forms of neuralgia. The duration of the disease is very chronic, and 
the treatment is often as unsuccessful as in other cases of hvsteria. 



CHAPTER IT. 

ANESTHESIA. 

Anaesthesia is the result of every morbid process in the sensory 
organs by which the perception of sensations is diminished or abolished. 
It may. therefore, involve every portion of the body in which sensory 
nerves are distributed. Cutaneous anaesthesia is the most common 
form of the disorder, and it alone will be considered in the present 
chapter. 

Two forms of sensation may be distinguished in the cutaneous 
nerves : tactile sensation and common sensation. Of these, the 
includes four varieties : 

1. Simple perception of contact with foreign bodies. 

2. Sensation of pressure. 
. ^ense of locality. 

4. Sensation of temperature. 
Th< farm of cutaneous sensibility comprises the perceptions 

of pain, electrical excitement, pleasure or discomfort, and such pecu- 
liar modifications of sensation as occur in tickling, itching, sexual 
:ement. el 
For the rec _ tion of sensory disorders, much time and patience 
iiiisite. Many of the methods that are em] r this purpose 

afford results which are highly interesting to the physiologist, but are of 



ANAESTHESIA. 783 

little practical importance from a clinical standpoint. Full particulars 
with regard to these methods of investigation may be found in Landois 
and Stirling's Physiology. 

The condition of simple tactile sensibility may be estimated by 
cautiously touching the skin of the patient, whose eyes have been 
previously bandaged, with the tips of the fingers, or with the head of a 
pin, or with a camel's-hair brush, or with a soft feather. 

The sense of pressure may be estimated by laying upon the surface 
of a well-supported limb, or other portion of the body, definite weights 
that can be increased at regular intervals by the addition of equal pieces 
of money, which can be piled upon one another. In this way a com- 
parison can be introduced between different parts of the bodily surface, 
and the minimal degree of pressure that can be perceived may thus be 
readily determined. 

For the investigation of the sense of locality it is necessary to deter- 
mine the power of accurately locating the point of irritation, and also 
to determine the size of each tactile circle within which different im- 
pressions excite single perceptions. The first can be ascertained by ask- 
ing the patient, when his eyes are bandaged, to accurately describe the 
points of contact with which the experiment is concerned. The diame- 
ter of the various tactile circles within which manifold impressions of 
contact are perceived as single sensations, may be readily determined 
by the use of the cesthesiometer. An instrument with blunted points 
is preferable, in order to avoid arousing painful sensations by the con- 
tact of sharpened points. The distance which separates the two points 
is readily measured upon the graduated scale of the instrument. If 
their simultaneous contact with the skin is perceived as a single sensa- 
tion, as if only one point were in existence, their distance must be 
increased until their contact is perceived as a double sensation. The dis- 
tance indicated by the scale is the semi-diameter of the tactile circle. 

The temperature sense may be most conveniently determined by suc- 
cessively touching the skin with test-tubes that have been filled with 
water of different temperatures. 

Painful sensations may be estimated by pinching the skin, or by 
pricking it with a pin, or by pulling the hair. In this way the absence 
of painful sensation may frequently be demonstrated, though tactile 
sensibility be retained. This condition is termed analgesia. In a 
somewhat similar way the sensitiveness of the skin to electrical im- 
pressions may be determined. 

Total anaesthesia is characterized by the absence of every variety 
of cutaneous sensibility. In cases of partial anaesthesia one or more 
varieties may be retained. In certain cases a transposition of percep- 
tions occurs, so that heat is perceived as cold, and vice versa. In cer- 
tain cases of dorsal tabes the prick of a pin is first perceived as a simple 
tactile impression that is, after a little time, succeeded by a sensation of 
pain. Painful impressions are sometimes doubled in a similar manner, 
and in certain cases a single impression is perceived as a three- or four- 
fold sensation (polysesthesia). Such modifications of sensation are 
dependent upon a peculiar retardation in the conduction of impressions 
to the brain. 



7^4 DISEASES OF THE NERVOUS SYSTEM. 

Outaneous anaesthesia may be either diffuse or circumscribed It is 

unilateral, when dependent upon diseases of the brain (herni-anesthesia), 
and in certain spinal diseases it may be limited to the inferior portion 
of the body and the lower extremities (paranesthesia). 

Etiology. The causes of anaesthesia may be located in the end- 
organs of the sensory nerves, or in the course of the peripheral paths 
between those structures and the brain, or in that portion of the brain 
where perception originates. Very little is known regarding the con- 
ditions in the end-organs of the nerves by which sensation is affected. 
The peripheral paths are principally influenced by changes in the cir- 
culation of the blood. The arrest of circulation in a limb is followed 
by anaesthesia in that portion. In many cases the application of cold 
is followed by loss of sensation, and the surgeon frequently takes 
advantage of this fact to produce surgical anaesthesia by the use of 
cooling sprays which lower the temperature of the surface. Certain 
chemical compounds, e. g.. caustic alkalies, acids, and carbolic acid, may 
thus destroy the sensibility of the skin, and the hypodermic use of 
cocaine or morphine is followed by a similar result. Many poisons have 
the power of destroying cutaneous sensibility, and it is a well-known 
fact that infective diseases are frequently followed by anaesthesia. The 
paralyzing influence of rheumatism, of traumatisms, inflammations, and 
compression, by which the nerves may be involved, requires no further 
mention. 

In certain cases cutaneous sensation is modified in such a way that 
the patient complains of abnormal sensations | paresthesia such as cold. 
stiffness, tension, prickling, and formication. In other cases, though 
anaesthesia is fully developed, intense neuralgia may still be experienced 
(anesthesia dolorosa). In such cases the path of sensation is inter- 
rupted at some point, so that the brain can no longer perceive sensations 
that are excited upon the cutaneous surface, but the disease or injury at 
the point of interruption is sufficient to excite in the brain perceptions 
which, in accordance with the well-known laws of physiology, are 
referred to that cutaneous surface with which the brain should com- 
municate by means of the injured nerve. 

3Tot>:>r dixturhanet* are readily associated with sensory disturbances, 
since the peripheral nerves so generally contain both motor and sens-ry 
fibres. 

Peripheral. ana:sthe$ia may be readily differentiated from that which 
is dependent upon diseases in the brain and spinal cord by the Loss : 
reflex movements which accompanies its development. W hen the 

- d is located above the spinal origin of the nerve, the reflex arc re- 
mains intact, and reflex movements may still be excited. 

Vat listurbances and trophic changes frequently accompany 

the development of anesthesia. 

Treatment. The causes of anesthesia must be removed if possible. 

The local affection of the skin may be treated with friction, massage, 

irritating liniments, and the application of electricity. The cathode 

1 be applied to the anesthetic surface, or the faradic brush may 

\< I with advantag , 



.DISEASES OF THE NERVES OF SPECIAL SENSE. ( 00 

Anaesthesia of the trigeminal nerve is not a very common disease, 
but it affords an excellent example of cutaneous anaesthesia. It is 
generally dependent upon exposure to cold, or upon injuries and 
diseases that involve the course of the nerve and its branches. It is 
usually a unilateral disease, and it is sometimes associated with paral- 
ysis of the motor portion of the nerve. Loss of sensation in the face 
can be readily demonstrated, and it is sometimes associated with paraes- 
thesia or with anaesthesia dolorosa. 

In certain cases the conjunctiva and cornea are affected, and contact 
with the cornea does not occasion winking or an increased secretion of 
tears, a circumstance which differentiates peripheral trigeminal anaes- 
thesia from that which is dependent upon central causes. Sneezing 
and other reflex consequences of irritating the mucous membrane of the 
nose and mouth can no longer be produced. The sense of taste is 
sometimes disturbed, even though the facial nerve be uninjured, 
a fact which seems to indicate that the sense of taste is not entirely 
dependent upon fibres derived through the chorda-tympani from the 
facial nerve. The existence of vasomotor and troi^hic disturbances is 
frequently demonstrated by redness, swelling, and heat in the territory 
of the trigeminal nerve, by ulceration in the mouth, and by the erup- 
tion of herpes. Inflammation of the eye (ophthalmia neuro-paralytica) 
is sometimes witnessed. This has been supposed to depend upon tro- 
phic changes under the influence of trophic fibres proceeding from the 
ganglion of Gasser, but it is probable that the disease is dependent upon 
anaesthesia of the cornea which renders it insensible to slight injuries 
and favors their infection by the microorganisms that excite inflam- 
mation. 



CHAPTEK V. 

DISEASES OF THE NERVES OF SPECIAL SENSE. 

Olfactory hyperaesthesia (hyperosmia) is a condition of the olfactory 
nerves which renders the patient capable of perceiving odors that are 
imperceptible to other persons ; and under the overpowering influence 
of ordinary smells they sometimes experience faintness, dizziness, or 
convulsions. 

Olfactory anaesthesia (anosmia) is a condition in which the sense of 
smell is more or less completely abolished. Such patients may still 
retain the power of perceiving pungent impressions, like those of 
ammonia or vinegar, which depend upon the functional integrity of the 
trigeminal nerve. In certain cases, although the sense of smell is com- 
pletely lost, there is complaint of disagreeable odorous sensations which 
are undoubtedly excited either by impressions that arise at the point of 
injury in the peripheral nerves, or in the central organs themselves. 
The sense of taste is frequently impaired, since much of our apprecia- 

50 



: DISEASES OF THE NERVOUS SYSTEM. 

tion of substances that excite the gustatory nerves is dependent upon 
simultaneous odoriferous impressions. So closely connected are the 
two senses that either one of them suffers when the special nerve of 
the other is paralyzed. 

Olfactory paresthesia (parosmia) is generally observed among insane, 
epileptic, or hysterical patients who complain of strange and disagree- 
able sensations which are either of peripheral or of central origin. 

Disorders of the Sense of Taste. 

They may have their origin in diseases of the trigeminal nerve, or of 
the glossopharyngeal nerve, or of the facial nerve. The anterior two- 
thirds of the tongue is innervated by the lingual nerve, which receives 
its special sensory fibres from the facial nerve through the intervention 
of the chorda tympani, while the posterior third of the tongue and the 
fauces are innervated by the glossopharyngeal nerve. Since the fibres 
of the chorda tympani are derived from the spheno-palatine ganglion 
through the intervention of the great superficial petrosal nerve, it is 
claimed by many that they are originally derived from the glosso- 
pharyngeal, which anastomoses freely with the trigeminal. 

The sense of taste may be resolved into the four qualities of sweet, 
sour, bitter, and salt. The susceptibility to sweets may be readily 
tested by causing the patient to protrude the tongue, which is then 
touched with a piece of paper, or with a glass rod, that has been suc- 
cessively dipped in the different test solutions. The patient should an- 
nounce his decision before withdrawing the tongue, and the mouth 
should be thoroughly rinsed with water after each trial. In this way it 
may be readily ascertained that in the normal condition, sweets are 
most readily perceived at the tip of the tongue, acids along its borders. 
while bitters are most distinctly recognized at the root of the organ. 

Gustatory hyperesthesia ihypergeusia) consists in an exaltation of 
the sense of taste, and is frequently encountered among nervous and 
hysterical persons. 

Gustatory anaesthesia (ageusia) consists in a reduction, or loss 
the sense of taste. It is frequently observed in connection with fevers, 
in which the tongue is thickly coated and the mouth is excessively dry. 
It is very commonly observed in cases of trigeminal and facial paralysis. 
It should be treated by the application of galvanism and by the removal 
of remediable eai> 

Gustatory paresthesia (parageusia) is most commonly observed 
among hysterical and insane patients, who often complain of most 
remarkable perversions of taste. 



ORGANIC DISEASES OF THE PERIPHERAL NERVES. 787 



CHAPTEE VI. 

ORGANIC DISEASES OF THE PERIPHERAL NERVES. 

Inflammation of the Nerves — Neuritis. 

Pathological Anatomy. Neuritis may be either interstitial when 
the connective tissue of a nerve is inflamed (perineuritis), or parenchy- 
matous when the nerve fibres themselves are involved. The disease 
may be circumscribed, or it may be progressive (neuritis migrans). 
When the disease is propagated from the periphery toward the central 
nervous organs, it is termed ascending neuritis ; when it follows the 
opposite course it is termed descending neuritis ; when it progresses 
discontinuously over the healthy portions of the nerve, it is termed dis- 
seminated neuritis. The favorite seats of neural inflammation are the 
vicinity of the joints, the bony canals through which the nerve trunks 
pass, and other points where they lie closely in contact with bony 
surfaces. 

Perineuritis may be either acute or chronic. In the acute form the 
nerve appears swelled and succulent, in consequence of the dilatation of 
its bloodvessels. Microscopical examination reveals an increase of 
nuclei and other evidences of inflammation in the vascular walls. The 
extra- vascular spaces are filled with round cells and colorless blood cor- 
puscles that are undergoing fatty degeneration, and sometimes red blood- 
corpuscles are abundantly extravasated. In severe cases blood stagna- 
tion is followed by parenchymatous degeneration also, and the changes 
that follow nerve section are developed in greater or less degree. The 
medullary sheaths of the nerve fibres degenerate and disappear, and 
the axis-cylinders in like manner become involved, while the nuclei in 
the sheath of Schwann are greatly multiplied. In severe cases sup- 
puration may occur, with complete destruction of the entire nerve 
structure. 

Chronic perineuritis may be either the result of acute inflammation, 
or it may be gradually developed as a chronic disease. The inflamed 
nerve becomes thickened by proliferation of the connective tissue, and 
it acquires a darker color by the deposit of blood pigment in its sub- 
stance. In many cases the nerve fibres disappear altogether, and the 
nerve becomes transformed into a simple band of connective tissue 
(sclerosis). In certain cases the nerve trunk becomes nodulated, so 
that it somewhat resembles a string of beads, and in this way actual 
neuromata may be originated. In many instances inflammatory adhe- 
sions between a nerve trunk and neighboring tissues may become the 
source of subsequent distress and disorder of function. 

Parenchymatous neuritis rarely occurs as an independent disease. 
The best example of its development is exhibited in a nerve which has 
been subjected to a solution of continuity. The peripheral portion of 



788 DISEASES OF THE NERVOUS SYSTEM. 

such a nerve undergoes changes that are effected by degenerative 
inflammation. 

Etiology. Neuritis is produced by exposure to cold, by injuries, 
by many infective diseases, by poisoning with lead and other metals, 
or with organic substances. It occurs in the course of metabolic dis- 
eases like diabetes, gout. etc.. and is associated with the development of 
the various forms of cachexia. It is often the result of inflammation 
that has been propagated from other organs. 

But in manv cases the causes of neuritis elude discovery. Migrating 
forms of inflammation sometimes pass from the periphery to the spinal 
cord without involving the intermediate nerves, or thev may. in like 
manner, extend from one side of the body to the other while the cen- 
tral portions escape without injury. It is probable that in many such 
cases, as in tetanus, the dissemination of inflammation is dependent 
upon the circulation of toxic products of bacterial origin. 

Symptoms. The course of an inflamed nerve may be frequently 
traced by a certain amount of superficial redness, and by evident swell- 
ing of the nerve trunk which is painful on pressure. In acute inflam- 
mation of the sensory nerves, tactile impressions are less readily per- 
ceived in its territory, though the perception of pain is greatly exalted 
(hyperalgesia). Loss of sensation follows serious injury of the nerve 
by inflammation. Various modifications of sensation (paresthesia) are 
frequently observed during the course of inflammation. Pain is fre- 
quently aggravated at night. Trophic changes are not uncommon, viz.. 
herpes, thickening and exfoliation of the epidermis, glossy fingers, 
changes in the nails and ulceration around their roots, swelling and 
stiffness of the joints, perforating ulcer of the foot, etc. 

When neuritis involves a motor nerve, various forms of spasm or 
fibrillary contractions of the nerves may be observed. Contractions 
and paralytic changes are frequent occurrences. Trophic changes in- 
vade the muscular fibres, which dwindle and exhibit degeneration of 
the contractile substance. The electrical irritability of the muscles is 
at first increased, but subsequently the reaction of degeneration is 
developed. 

When mixed nerves are invaded by inflammation, sensation disappears 
earlier than the power of motion, and it is also the first to reappear 
during recovery. 

Chronic neuritis is characterized by the same course and symptoms 
that are manifested by the acute form of the disease, but they are de- 
veloped more gradually and with less severity. It is frequently asso- 
ciated with epilepsy, hysteria, and severe mental disorders. 

DIAGNOSIS. Neuritis must be distinguished from neuralgia, which 
mav be recognized by the more intermittent character of its pain, and 
by the existence of pressure points. Muscular rheumatism is marked 
by a painful condition of the muscles, especially when they are subjected 
to pressure. 

PROGNOSIS. The duration of neuritis is frequently very tedious. In 
many cases recovery never occurs, and the cessation of inflammation is 
followed by permanent signs of injury. Many cases of acute neuritis 



ORGANIC DISEASES OF THE PERIPHERAL NERVES. 789 

are followed by complete recovery, but there is always dauger that the 
inflammatory process may invade the spinal cord. 

Treatment. Treatment must be addressed to the causes of neuritis 
whenever they can be discovered and removed. Local treatment is 
greatly facilitated by perfect repose, and by the use of mercurial oint- 
ment, tincture of iodine, cups, blisters, and hypodermic injections of 
morphine for the relief of pain. The galvanic current is of great value 
in the treatment of neuritis. The anode should be placed over the 
region of pain, while the cathode rests upon an indifferent point. The 
use of the faradic brush is sometimes attended with considerable relief. 
Chronic cases are benefited by massage and by hot baths. The actual 
cautery may sometimes be applied with advantage. 

Multiple Neuritis. 

Etiology. Multiple neuritis consists in the wide diffusion of an 
inflammatory process which simultaneously invades many of the periph- 
eral nerves. Its course is sometimes so rapid and so violent that it 
suggests an infective cause. In its chronic form it is undoubtedly 
caused in certain cases by an infective poison, e. g., beri-beri, or JcaJce, 
of the Japanese. 

Multiple neuritis frequently occurs as a secondary consequence of 
such infective diseases as diphtheria, typhoid fever, malarial fever, 
syphilis, tuberculosis, etc. It frequently results from poisoning with 
lead and other metals. Alcohol, ergot, etc., frequently produce the 
disease, and its connection with injuries and exposure to cold scarcely 
needs mention. 

Symptoms. Acute multijjle neuritis is frequently ushered in by the 
symptoms of fever. The seat of the disease is occupied by various 
forms of pain and paresthetic modifications of sensation. There is 
complaint of weakness, stiffness, and difficulty of movement in the 
affected portions of the body. Sometimes complete paralysis is de- 
veloped. The electrical irritability of the paralyzed muscles and nerves 
rapidly disappears, and the reaction of degeneration is soon apparent. 
Atrophy rapidly involves the affected muscles, and they may finally 
become contractured. 

Sensory disturbances are less frequent and less extensively developed. 
Vasomotor changes involving the color and condition of the skin are 
frequently present. The trophic functions of the nerves are also dis- 
turbed. The hair becomes gray and increased in quantity over the 
affected parts, the nails become brittle and frequently fall off, the epi- 
dermis is thickened, and perspiration is often increased. Sometimes 
gangrene attacks the extremities ; swelling of the joints and sheaths of 
the tendons frequently occurs. 

The cutaneous and tendinous reflexes usually disappear, since the 
reflex path to the spinal cord is interrupted. Not unfrequently the 
affected nerves are sensitive to pressure. In certain cases the disease 
progresses widely, and death may result from invasion of the pneumo- 
gastric nerve. The sympathetic system itself may become involved, 
giving occasion for the incidence of so called visceral crises, characterized 



790 DISEASES OF THE NERVOUS SYSTEM. 

by palpitation, vomiting, diarrhoea, and deep-seated visceral pain. The 
bladder and the rectum, however, almost always escape from implication 
in the disease. 

Pathological Anatomy. The inflammatory process in acute mul- 
tiple neuritis is, in certain cases, principally located in the connective 
tissue, while in others the parenchyma of the nerves is chiefly involved. 
The changes correspond with those which have been already described 
in the section on neuritis. In certain cases the inflammatory process is 
disseminated throughout the nervous parenchyma, in the form of islets 
that leave considerable portions of tissue uninjured (segmental neuritis). 
The brain, spinal cord, and spinal nerve roots in uncomplicated cases 
exhibit no evidences of disease. 

Diagnosis and Prognosis. Acute and rapidly ascending cases of 
neuritis must be distinguished from acute ascending spinal paralysis, 
and from poliomyelitis, by the existence of sensory disturbances which 
are absent in those diseases. The prognosis is always serious on account 
of the danger of a fatal result from invasion of the pneumogastric nerve. 

Treatment. Acute multiple neuritis should be treated with as 
large and as frequently repeated doses of salicylic acid as can be toler- 
ated by the patient. Antipyrine, acetanilide, and phenacetine may 
also be given as required. Severe pain must be relieved by the internal 
use of opiates, with chloroform liniment externally. After the acute 
stao-e is passed, electricity should be applied to the affected nerves and 
muscles. Iodide of potassium is then useful ; also treatment with baths 
and massage. 

Toxic Paralysis. 

Saturnine paralysis is one of the later symptoms of lead poisoning, 
though it occasionally appears at an earlier period of the disease. The 
symptoms develop gradually under the form of weakness, atrophy, and 
finally paralysis of certain muscles, especially those of the upper ex- 
tremity, which are innervated by the radial nerve. Generalization of 
the paralysis rarely occurs. The disease ordinarily commences in the 
right arm, invading the common extensor muscles of the fingers; then 
follow the extensor muscles of the wrist and of the thumb ; while the 
muscles of the ball of the thumb and the interosseous muscles are the 
last to yield. The supinator muscles are seldom invaded, unless the 
biceps, internal brachial, and deltoid muscles are also affected. The 
hand hangs perpendicularly from the extremity of the radius, producing 
the characteristic appearance known as drop wrist. 

The muscles and nerves soon lose their excitability by the faradic 
current and the reaction of degeneration is rapidly developed. Partial 
retention of electrical excitability indicates the possibility of recovery 
within a comparatively brief period, but when the reaction of degenera- 
tion is fully developed, recovery is only possible after three or four 
months. The mechanical irritability of the muscles is increased, and 
fibrillary contractions are sometimes visible in the paralyzed muscles. 
The cutaneous and tendinous reflexes disappear, the muscles become 
atrophied, and trophic changes frequently occasion swelling of the 
phalangeal joints and tendinous sheaths. 



ORGANIC DISEASES OF THE PERIPHERAL NERVES. 791 

Pathological Anatomy. The muscular fibres dwindle, the nuclei 
of the sarcolemma are multiplied, the connective tissue proliferates, and 
sometimes undergoes fatty degeneration. The nerves undergo degenera- 
tive atrophy to which, in all probability, the muscular changes are 
secondary. 

Diagnosis. Lead palsy may be distinguished from peripheral 
paralysis of the radial nerve by the longer preservation of contrac- 
tility in the supinator muscles, and by the absence of any considerable 
sensory disorder. 

Prognosis. The prognosis is dependent upon the electrical reactions 
of the muscles. Relapses are frequent, in consequence of repeated ex- 
posure to the poisonous influence of lead. 

Treatment. Treatment must have reference to the removal of all 
causes by which lead can be introduced into the system. Iodide of 
potassium should be given in doses of five grains three times a day, in 
order to promote the removal of lead from the tissues. Hot sulphur- 
baths should be ordered daily, and as a substitute for the natural waters, 
two or three ounces of sulphide of potassium may be dissolved in the 
bath. Descending galvanic currents should be applied to the muscles 
every day, and the faradic current may be employed whenever the 
muscles can be made to contract under its influence. Hypodermic 
injections of strychnine are frequently recommended. 

Mercurial paralysis is frequently observed among laborers in quick- 
silver mines. It produces neither muscular atrophy nor any modifica- 
tion in the electrical reactions, but disturbances of sensation are ap- 
parent. The prognosis is favorable, and the treatment should be the 
same as that which is recommended in cases of lead paralysis. Some- 
what similar paralytic conditions have been observed from the effects of 
copper and zinc. 

Arsenical paralysis is usually the result of acute arsenical poison- 
ing. It involves chiefly the lower extremities. The muscles become 
rapidly atrophied, and painful disturbances of sensation accompany 
the course of the disease. Sometimes the bladder participates in the 
paralysis, and occasionally the upper extremities are invaded. The 
extensor muscles are principally affected, and the electrical reactions 
follow the same course as in cases of lead poisoning. Recovery is 
tedious and sometimes incomplete. The muscular fibres dwindle and 
exhibit the appearance of waxy or fatty degeneration, which also in- 
volves the connective tissue. In certain cases the anterior cornua of 
the gray matter in the spinal cord is inflamed, but in the majority of 
cases the disease is limited to the peripheral nerves. The treatment is 
the same as for lead paralysis. 

Phosphorus paralysis is observed in cases of poisoning with phos- 
phorus. It takes the form of a partial paralysis involving one limb, or 
the lower extremities, and disturbances of sensation are also developed. 
The location of the disease is usually in the peripheral nerves, but some- 



792 DISEASES OF THE NERVOUS SYSTEM. 

times the spinal centres are invaded. Treatment as in the preceding 
forms of paralysis. 

Oases of paralysis are sometimes observed as a consequence of poi- 
soning with coal gas or with the vapor of carbon disulphide. 

Paralysis from ergot (ergotism) is observed after the use of spurred 
rve. It occasions muscular atrophy, severe pain, and other disturbances 
of sensation. The precise locality of the disease is still uncertain, and 
is possibly not the same in all cases. 

Alcoholic paralysis frequently follows chronic indulgence in the use 
of alcohol. The extensors of the forearm and of the leg are chiefly 
involved by the disease, and it is accompanied by muscular atrophy and 
disturbances of sensation. Tremor is frequently observed in the paral- 
yzed limbs, and the nerves and muscles are sensitive to pressure. The 
electrical excitability of the nerves and muscles is diminished, and fre- 
quently gives way to the reaction of degeneration. Severe pain and a 
great variety of paresthetic sensations are often experienced, especially 
during the night-time. Various degrees of hyperesthesia and anaes- 
thesia may be developed. The tendinous reflexes disappear, but the 
cutaneous reflexes usually remain without change. The bladder and 
rectum are not involved in the disease. Trophic changes are some- 
times observed, and the cerebral nerves are occasionally involved, espe- 
cially the ocular nerves and the pneumogastric nerve. The pupils are 
frequently contracted or sluggish, and optic neuritis sometimes exists. 
Intellectual disturbances are of frequent occurrence, and there is great 
complaint of sleeplessness. Ataxic symptoms are frequently developed 
as a consequence of extensive peripheral neuritis (alcoholic pseudo- 
tabes). 

Pathological Anatomy. Many of the nerve fibres are deprived of 
their medullary sheaths, and the nuclei of the sheath of Schwann are 
increased in number. In the muscles, the connective tissue is increased. 
and the muscular fibres have undergone atrophy. The spinal cord 
remains free from change. 

Diagnosis. Alcoholic paralysis is frequently confounded with tabes 
dorsalis, in which disease the electrical excitability of the muscles and 
nerves is usually unchanged, and disordered pupillary reaction is fre- 
quently present : while in the alcoholic disease the girdle sensation and 
paralytic conditions of the bladder and rectum that are so common in 
tabes are absent. 

Prognosis and Treatment. The prognosis depends largely upon 
the ability of the patient to resist his inclination for alcohol. The 
treatment should consist in the daily use of warm baths, with iodide of 
potassium, salicylic acid, and strychnine internally, accompanied by the 
use of electricity and stimulating frictions externally. 



PART XI. 

DISEASES OF THE SPINAL CORD AND 
MEMBRANES. 



CHAPTER I. 

PRELIMINARY CONSIDERATIONS. 

Since the spinal cord does not occupy the whole extent of the spinal 
column, but terminates between the first and second lumbar vertebrae, 
diseases which occupy the spinal column below that point do not involve 
the spinal cord but the cauda equina. It is also desirable to remember 
that the cervical and lumbar portions of the spinal cord are consider- 
ably thicker than the dorsal portion. The cervical swelling occupies 
the space between the upper border of the atlas and the second tho- 
racic vertebra, while the lumbar enlargement extends from the tenth 
dorsal vertebra to the first lumbar vertebra. 

Since the spinal nerves follow a descending course as they leave the 
spinal cord to enter the inter-vertebral canals, their internal points of 
origin are considerably above the level of their apparent emergence 
along the sides of the spinal column. (Fig. 155.) The eight cervical 
nerves have their origin between the foramen magnum and the sixth 
cervical vertebra. The twelve dorsal nerves originate between the 
seventh cervical vertebra and the tenth dorsal. The five lumbar nerves 
originate between the tenth dorsal vertebra and the lower portion of the 
twelfth dorsal vertebra ; while the five sacral nerves originate between 
the twelfth dorsal vertebra and the first lumbar vertebra. 

The spinal dura mater is not closely applied to the inner surface of 
the bony canal, but is widely separated from it by fatty tissue that con- 
tains numerous veins. For this reason diseases of the vertebra which 
invade the sub-dural space may lead to dangerous pressure upon the 
spinal cord. 

Spinal diseases are not always followed by changes in the spinal cord 
that can be recognized with the naked eye after death. Microscopical 
examination of fresh specimens which have been teased with needles in 
a three-quarter per cent, solution of chloride of sodium, or in glycerine, 
should not be neglected. Such specimens may also be treated with 
perosmic acid, or may be stained with carmine or other colors before 
being subjected to examination. 

But in a large proportion of cases, careful and methodical hardening 



r 94 DISEASES OF THE SPIXAL CORD AND MEMBRANES. 



Fig. 155. 




Motor. 

Stemo-niastoid. 

Trapezius. ) 

Rhomboids and rota- ', 

tors of humerus. i 

Diaphragm. J 

Deltoid, biceps, brachi- 

alis, supinators. 
Serratus. 
Tricejps, extensors of I 

wrist and fingers. 

and pronators. 
Flexors of wrist and j 

long flexors of fingers. J 

Intrinsic muscles of | 
hand. 



Sensory. Reflex. 

Neck and scalp. 



Neck and shoulder. 



Outer aspect of arm and 
forearm. 

Anterior and posterior 
aspects of arm. fore- 
arm, outer half of 
hand, and 2}4 fingers. 

- : .\pular. 

Inner aspect of arm, 
forearm, inner half of 
hand, and 2}{ 2 fingers. 



Intercostal muscles. 



- Abdominal muscles. 



Front of thorax. 
j Ensiform cartilage. 



Abdomen. 
Umbilicus. 
I" Buttock, upper part. 



I Epigastric. 



Abdominal. 



Flexors, hip. 
Extensors, knee. 

Adductors 1 

I 
Abductors \ Hip. 

I 
Extensors (?) J 

Flexors, knee 

Muscles of leg moving 
foot. 

Perineal and anal mus- 
cles. 



Groin and scrotum "] 



>nt). 

r Outer side "\ 

Thigh ■] Front side I 

(, Inner side J 



Leg. inner side. 
Buttock, lower part. 
Back of thigh. 

f Leg and foot, except 

i inner part. 

Perineum and anus. 

f Skin from coccyx to 
\ anus. 



! Cremasteric. 
j Kno:-, 



Gluteal. 
Foot-clonus. 

Plantar. 



table showing the approximate relation to the spinal nerves of the various sensory and 
reflex functions of the spinal cord. (After Gow - 



PRELIMINARY CONSIDERATIONS. 795 

of the cord is necessary before it can be microscopically examined. For 
the proper methods of preparing and mounting specimens, full direc- 
tions are given in the text-books on histology and the use of the 
microscope. 

The diagnosis of spinal diseases must necessarily be dependent first, 
upon the location of the disorder, and second, upon the determination 
of the nature and cause of the local lesion. The character of the 
functional disturbance which follows a spinal lesion is but slightly de- 
pendent upon the nature of the lesion. It merely expresses the extent 
and severity of the injury to which the structures of the cord have 
been subjected either by violence or by disease. Hence the great im- 
portance of the localization of symptoms which is rendered possible by 
the physiological investigations of modern times. In the gray matter 
of the anterior cornua of the spinal cord may be distinguished three 
separate groups of large ganglionic cells, which may be differentiated as 
an interior, a middle, and an external group, which, by the axis cylinder 
processes of their constituent cells, give origin to the fibres of the an- 
terior spinal nerve roots. Their injury produces paralysis and rapid 
wasting of the muscles with which they are directly connected, accom- 
panied by the reaction of degeneration in the paralyzed nerves and 
muscles. Similar consequences follow injuries of the anterior spinal 
nerve roots which convey motor and trophic impulses to the muscles, 
bones, joints, and tendons with which they are connected. 

In the posterior cornua of the gray matter, the ganglionic cells are 
not grouped in clusters, but are scattered throughout the gray matter. That 
they possess trophic functions is apparent from the fact that their injury 
or disorder leads to trophic changes and gangrene of the skin with 
which they are in communication. 

Lying in the isthmus that connects the anterior and posterior cornua 
is a column of large ganglionic cells called the vesicular column (Clark's 
column). The processes of these cells are connected with the direct 
cerebral tract in the postero-lateral portion of the cord ; but their pre- 
cise function is unknown. 

The white substance (Fig. 156) of the cord is divided into : 

1. The direct pyramidal tract, which consists of fibres (d.P.) that 
have not decussated in the medulla oblongata, but which accomplish their 
decussation in the anterior commissure of the cord. 

2. The crossed pyramidal tract (cr. P.), which consists of longitudinal 
fibres from the brain, which have completed their decussation in the 
medulla oblongata, and enter into communication with the ganglionic 
cells in the anterior cornua. 

3. The direct cerebellar tract (C.b.) 

4. The funiculus cuneatus (r.z.) (column of Burdach), which consists 
largely of commisural fibres that connect together the different segments 
of the posterior cornua. They finally terminate in the nucleus of the 
funiculus cuneatus and in the olivary body. 

5. The funiculus gracilis (cr. s.lr.) (column of Goll), which consists 
largely of fibres that originate in the inter-vertebral ganglia and termi- 
nate in the nucleus of the funiculus gracilis upon the floor of the fourth 



796 DISEASES OF THE SPINAL CORD AXD MEMBRANES. 

ventricle, from which new fibres pass onward to the tegmentum, corpora 
quadrigemina, and thalamus. 

The posterior spinal nerve roots send a portion of their fibres directly 
into the substance of the posterior cornua, while the remainder pass 
through the funiculus cuneatus before they enter the posterior cornua. 
A decussation of the sensory path takes place immediately after its 
entrance into the cord, so that injury of one-half of the spinal cord 
is followed by loss of motion upon the same side and loss of sensa- 
tion upon the opposite side of the body. The fibres which convey 
impressions of tickling cross first ; then follow the fibres that con- 
vey painful impressions; and finally those which convey impres- 
sions of temperature. Those fibres which are concerned with the mus- 
cular sense remain uncrossed. Tactile impressions find their way to 
the brain through the posterior columns of the cord, while painful im- 
pressions pass upward in the gray matter. 

Fig. 156 




Diagram to illustrate the general arrangement of the several tracts of white matter in the 
spinal cord. (Sherrington.) 

cr.P. Crossed pyramidal tract. d.P. Direct pyramidal tract C.b. Cerebellar tract. 
s.lr. and cr. Indicate the median posterior tract, asc.a.l. The antero-lateral ascending 
tract. desc.L The antero-lateral descending tract. L. Lissauer's zone. 



In certain conditions of disease reflex movements may be either in- 
creased, weakened, or altogether abolished. Their increase occurs 
whenever injury or disease involves the inhibitory fibres that lie in the 
pyramidal tracts and connect the central convolutions of the brain with 
the gray matter of the anterior cornua of the cord. Reflex movements 
are weakened or abolished whenever any portion of the reflex are be- 
tween a sensory nerve end-organ and the corresponding muscles is im- 
paired or completely interrupted. 

Vasomotor functions are disturbed by diseases or injuries of the 
spinal cord. The vasomotor paths are supposed to lie in the lateral 
columns, from which nerve fibres pass into the gray matter of the cord, 
and thence emerge with the anterior nerve roots, and find their way to 
the bloodvessels. These paths do not appear to undergo decussation. 
In the gray matter of the cord are undoubtedly situated independent 



PRELIMINARY CONSIDERATIONS. 797 

vasomotor centres which can influence the bloodvessels without the 
intervention of the brain. 

In the lowest portion of the lumbar division of the cord, near the level 
of the emergence of the third and fourth sacral nerves, is situated the 
ano-vesical centre which innervates the muscles of the bladder and 
rectum. In its immediate neighborhood is the spinal centre for erection 
and ejaculation. In the lower portion of the cervical and the upper 
portion of the dorsal cord is situated a spinal centre which influences 
the movements of the pupils. From this centre emerge fibres, through 
the anterior nerve roots, which enter the cervical portion of the sympa- 
thetic nerve, and finally reach the iris. Irritation of this centre produces 
dilatation of the pupil ; and its paralysis is followed by pupillary con- 
traction, upon the same side with the injury. This form of spinal myosis 
is frequently observed in spinal diseases, and is characterized by the 
fact that the pupil does not react under variations of light, but does vary 
during movements of accommodation. 

It appears that the large ganglionic cells in the anterior cornua are 
not grouped in connection with single nerves, but that they are con- 
nected by their fibres with muscular groups which perform similar 
functions. (See Fig. 155.) Thus it appears that : 

The fourth cervical nerve innervates the supra- and infra-spinatus 
muscles, and probably the teres minor muscle. 

The fifth cervical nerve innervates the biceps and supinator muscles, 
and probably the internal brachialis and supinator muscles. 

The sixth cervical nerve innervates the sub-scapular, pronator, teres 
major, latissimus dorsi, pectoralis major, triceps, and serratus magnus 
muscles. 

The seventh cervical nerve innervates the extensor muscle of the 
hand. 

The eighth cervical nerve innervates the flexors of the hand. 

The first dorsal nerve innervates the interosseous and other small 
muscles of the hand. 

The third lumbar nerve innervates the adductors and flexors of the 
thigh. 

The fourth lumbar nerve innervates the extensors of the knee. 

The fifth lumbar nerve innervates the flexors of the leg. 

The first and second sacral nerves innervate the glutaeus muscles, 
the muscles of the calf and external surface of the leg, and the exten- 
sor and small muscles of the foot. 

The third sacral nerve contains the erigent nerve fibres, and inner- 
vates the levator ani muscle. 

The fourth sacral nerve innervates the muscles of the bladder and 
rectum. 

Lesions of the spinal cord at the level of the twelfth dorsal vertebra, 
involve the lower portion of the lumbar enlargement, and produce 
paralysis of the muscles innervated by the sciatic nerve, with the excep- 
tion of the tibialis anticus. The bladder and rectum are frequently 
paralyzed, and the reflexes are abolished. Anaesthesia occupies the 
lower limb, with the exception of the external and inner surfaces of the 



798 DISEASES OF THE SPIXAL COED AND MEMBRANES. 

thigh and the inner surface of the leg. which are innervated by the an- 
terior cutaneous, crural, and obturator nerves. 

A lesion in the upper part of the lumbar enlargement produces motor 
and sensory paralysis of the entire lower extremity. 

A lesion of the dorsal portion of the cord, at the level of the eighth 
dorsal vertebra, produces paralysis of the lower extremity, anaesthesia 
as high as the navel, increase of the reflexes, and priapism. 

A lesion at the level of the fifth dorsal vertebra produces similar con- 
sequences, and also an extension of anaesthesia to the level of the ensi- 
form cartilage. 

A lesion in the lower portion of the cervical cord produces paralysis 
of everything below, and of the muscles in the upper extremity that are 
innervated by the ulnar nerve ; while anaesthesia reaches the upper por- 
tion of the thorax. 

A lesion in the cervical cord extending from the fifth to the eighth 
cervical nerves produces an extension of paralysis to the muscles that 
are innervated by the radial nerve, with the exception of the supinator 
longus. 

A lesion in the upper portion of the cervical enlargement of the cord, 
involving the fourth and fifth cervical nerves, produces paralysis of the 
arm. body. leg. diaphragm, and anaesthesia extending upward to the level 
of the clavicle, together with an increase of the reflexes. 

Diseases of the spinal cord are said to be systematized when they are 
limited to certain ganglionic groups, or are restricted to particular 
columnar paths in the white substance of the cord. 

When different portions of the spinal tissue are indiscriminately in- 
volved the disease or injury is said to be unsystematized. Systematized 
diseases may be simple when only one functional group or tract is in- 
volved, or combined when several are simultaneously invaded. Diseases 
which are accompanied by no discoverable changes in the tissues are 
termed functional diseases of the spinal cord. 



CHAPTEE II. 

DISEASES OF THE SPINAL MENINGES. 

External Inflammation of the Spinal Dura Mater — Pachymeningitis 

Spinalis Externa. 

Pathological Axatomy. Tubercular and syphilitic diseases of the 
spinal column may originate an inflammatory process upon the external 
surface of the dura mater, in the loose connective tissue that connects it 
with the bony structures of the spinal column. It is occasionally ex- 
cited bv other inflammatory diseases in the neighborhood. It usually 
occupies a circumscribed portion of the dura mater, generally its pos- 
terior surface. The ordinary evidences of exudation are present ; 



DISEASES OF THE SPINAL MENINGES. 799 

suppuration sometimes occurs and may result in caseation or in exten- 
sive thickening and adhesion of the affected tissues. Sometimes the 
inner surface of the dura mater and the pia mater participate in the 
inflammatory process. 

Symptoms. The symptoms may be referred to irritation of the 
spinal nerve roots, followed by paralysis, and, in certain cases, by com- 
pression and secondary inflammation of the spinal cord. The disease 
commences with a sensation of stiffness in the back, sensitiveness to 
pressure upon the spinous processes of the vertebrae, and pain when a 
hot sponge, or the galvanic cathode, is moved up and down the spine. 
Frequently a sense of constriction around the body results from irrita- 
tion of the posterior nerve roots. Not unfrequently paroxysms of neu- 
ralgiform pain are experienced, and are accompanied by spasms and 
contractures in the muscles of the extremities. Various paresthetic 
disorders of sensation frequently exist, and, during the paralytic stage 
of the disease, ancesthesia is developed. Muscular paralysis, atrophy, 
and the reaction of degeneration follow compression of the anterior 
nerve roots. If the spinal cord itself is compressed, motor and sensory 
paraplegia, paresthesia, exaggeration of the reflexes, and disorder of 
the functions of the bladder and rectum are developed, and bedsores 
may occur. The disease assumes a chronic form, and is usually fatal, 
though recovery has been sometimes observed. 

Treatment. Treatment must depend, in great measure, upon the 
causes of the disease. Its general course should be that which will be 
described in the section on myelitis. 

Internal Inflammation of the Spinal Dura Mater — Pachymeningitis 

Spinalis Interna. 

Pathological Anatomy. Internal spinal pachymeningitis is an 
inflammation and extensive proliferation of the connective tissue, in- 
volving the inner surface of the dura mater, and usually extending to 
the arachnoid membrane and the pia mater. It is generally restricted 
to the lower portion of the cervical enlargement of the cord, and prin- 
cipally involves the posterior part of the membranes. It produces 
compression of the spinal nerve roots at the seat of the disease, and it 
may also occasion similar pressure upon the spinal cord itself. In cer- 
tain cases the inflammatory exudation contains blood, which may be 
effused in considerable quantity, constituting hemorrhagic pachymen- 
ingitis. This condition is frequently associated with similar states of 
the cerebral dura mater. It generally results from chronic alcoholism, 
or from insanity. 

Symptoms. The disease is chronic, and during the first two or three 
months the symptoms principally indicate irritation of the affected 
nerves, which is finally succeeded by paralysis and muscular atrophy. 

During the stage of irritation pain is experienced in the upper part 
of the spinal column, in the occiput, and in the joints of the upper ex- 
tremities. The spinous processes are not tender on pressure, but there 
is a sensation of stiffness in the neck, and of constriction around the 
thorax. The painful sensations are liable to paroxysms of aggravation, 



800 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

and various forms of hyperesthesia arid paresthesia may be remarked, 
especially in the upper extremities. Trophic changes, in the form of 
cutaneous eruptions, are frequent. Muscular spasms of a tonic or 
clonic character are not uncommon, and the muscles become rigid and 
contractured. 

During the paralytic stage of the disease, fibrillary contractions, 
muscular paralysis, atrophy, and the reaction of degeneration are de- 
veloped. The skin becomes anaesthetic. Since the disease usually 
involves the lower portion of the cervical cord, paralysis chiefly affects 
the median and ulnar nerves, so that the flexor muscles of the hand and 
wrist are paralyzed, while the intact radial nerve maintains the ex- 
tensor muscles of the hand in a state of contraction. The hand is, there- 
fore, drawn into a position of dorsal extension, while the second and third 
phalanges of the fingers are flexed in consequence of the paralysis of 
the interosseous muscles. If, on the contrary, the disease extends up- 
ward so as to involve the entire cervical plexus, the extensor muscles 
of the forearm are paralyzed, and the hand drops at the wrist. 

Compression of the spinal cord produces the usual paralytic condi- 
tions that are developed below the seat of pressure. 

Diagnosis. Pachymeningitis may be differentiated from progressive 
muscular atrophy by the symptoms of irritation which characterize its 
earlier stages ; by its limitation to the cervical portion of the cord ; 
and by the subsequent development of the symptoms of pressure- 
paralysis below the seat of the disease. In like manner it may be dis- 
tinguished from amyotrophic lateral sclerosis, in which sensory dis- 
turbances and nervous irritation are absent ; and in which death 
usually results by extension of the disease to the medulla oblongata. 
Tubercular diseases and tumors involving the spinal column and me- 
ninges must be differentiated by attention to their history and progress. 

Treatment. The treatment of pachymeningitis is the same as that 
of acute or chronic myelitis. 

Acute Spinal Meningitis — Meningitis Spinalis Acuta. 

Etiology. Acute spinal meningitis is an acute inflammation of the 
arachnoid membrane and pia mater of the spinal cord. It sometimes 
involves the spinal membranes alone, but it may extend to the corre- 
sponding membranes of the brain ; or cerebral meningitis may be propa- 
gated downward until it involves the membranes of the spinal cord, 
constituting what is termed cerebrospinal meningitis. These com- 
bined forms of the disease are occasioned either by tubercular or by 
special infection. The ordinary forms of spinal meningitis are excited 
by exposure to cold, by injuries involving the spinal column and mem- 
branes, or by the extension of inflammatory diseases from other portions 
of the body, or as a result of infective diseases, or from menstrual or 
hemorrhoidal suppression. 

Pathological Anatomy. Meningeal inflammation is character- 
ized by a stage in which the phenomena of hypercemia are most con- 
spicuous. This is succeeded by a period of exudation ; and the last stage 
of the disease is occupied by the processes of reabsorption and recovery. 



DISEASES OF THE SPINAL MENINGES. 801 

The products of exudation may be either simply fibrinous, or they may 
contain pus and blood corpuscles in greater or less quantity. The 
medulla oblongata is rarely involved in the process. Though recovery 
may frequently occur, thickening and adhesion of the meninges often 
persist, and may lead to serious consequences. In certain cases the 
dura mater and neighboring connective tissue participate in the inflam- 
matory processes. The nerve roots and the substance of the spinal 
cord itself are usually more or less involved, since the pia mater sends 
numerous processes into the interior of the cord. The white matter is 
more extensively invaded than the gray, but in both tissues it is not an 
uncommon event to discover evidences of proliferation in the neuroglia 
and swelling of the ganglionic cells. 

Symptoms. Spinal meningitis is ushered in by vague disturbances 
of the system which culminate usually in a severe chill, followed by 
high fever, with a temperature of 103° or 104° F. Pain and stiffness 
are experienced along the spinal column, but are not increased by 
pressure upon the spinous processes, or by the application of a hot 
sponge or the galvanic cathode. During the period of congestion and 
irritation of the spinal nerve roots there is complaint of neuralgiform 
pains which radiate along the nerves of the body and of the extremities. 
There is exaltation of cutaneous sensibility, and the muscles are very 
sensitive to pressure. Motor irritation is indicated by tonic or clonic 
muscular spasm, or by the development of rigidity and muscular con- 
traction, especially in the territory of the extensor muscles. The 
cervical muscles exhibit tonic contracture, and the head is drawn back- 
ward, so that in certain cases the body rests upon the occiput and the 
sacrum alone. The patient dreads movement of every kind, and his 
position cannot be shifted without occasioning great distress. The act 
of respiration is rendered difficult by the rigidity of the muscles of the 
body. Urine and feces are retained in consequence of the spasmodic 
condition of the sphincters of the bladder and rectum. The pupils are 
contracted or irregular, in consequence of irritation of the cilio-spinal 
nerves. 

The disease may subside without further progress, but in many cases 
the stage of paralysis is now gradually developed, though many of its 
symptoms frequently appear during the period of irritation and excite- 
ment. Anaesthesia and analgesia now succeed to the previous sensory 
exaltation. The muscles relax, grow weaker, finally become paralyzed, 
and exhibit the reaction of degeneration. The reflexes disappear, the 
detrusor muscle of the bladder becomes paralyzed, causing retention of 
the urine, and at last the sphincter also gives way, causing incontinence 
of urine. 

Recovery is still possible, though paralysis and atrophy may per- 
sist permanently in certain muscular groups. The principal danger to 
life is developed when the inflammatory process extends upward and 
involves the medulla oblongata. The functions of respiration, circu- 
lation, speech, and deglutition are gradually paralyzed, and death fol- 
lows from asphyxia, cardiac paralysis, or excessive elevation of the 
temperature. 

51 



802 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

Diagnosis. Spinal meningitis must be differentiated from rheumatism 
of the spinal muscles, a disease in which fever, muscular spasm, modifi- 
cations of sensation, and disorders of the bladder are absent. In tetanus. 
the bladder and the sensory nerves are not involved, but the muscles of 
mastication are in a condition of tonic contracture, and spasms are 
readily excited or increased by peripheral irritation. Acute myelitis 
differs from meningitis in the comparative insignificance of the symp- 
toms of irritation by which it is accompanied and by the early appear- 
ance of paralysis. In cases of myelitis pain is not increased by move- 
ments of the body, and the patient remains motionless in consequence 
of the impossibility of exertion : while in meningitis bodily movement is 
attended with great pain, and the patient is motionless through dread 
of the suffering that attends muscular effort. Myelitis is frequently 
attended by trophic changes in the skin, and by speedy paralysis of the 
bladder and decomposition of the urine, disorders which appear at a very 
late period, if at all, in meningitis. 

Prognosis. The duration of the disease is frequently very brief, 
though sometimes it passes into a chronic form, and lingers for weeks 
or months, or may leave traces of its existence during a lifetime. It is 
always a dangerous disease, especially when the neighborhood of the 
medulla oblongata is approached. 

Treatment. Acute spinal meningitis should be treated like acute 
myelitis. 

Chronic Spinal Meningitis — Meningitis Spinalis Chronica. 

Etiology. Chronic spinal meningitis may be the result of the acute 
form of the disease, or it may gradually develop as a consequence of 
causes identical with those which produce the acute variety. Alco- 
holism, syphilis, leprosy, chronic diseases attended with stagnation of 
the blood, and chronic diseases of the spinal cord, are predisposing 
causes of chronic meningitis. 

Pathological Anatomy. Chronic meningitis usually involves the 
lower portion of the spinal membranes, and is frequently disseminated 
in circumscribed patches of inflammation. It is characterized by 
thickening of the membranes, which sometimes undergo calcification or 
ossification. The inflamed tissues become deeply pigmented and ad- 
herent to each other. The spinal fluid is increased in quantity, and 
becomes more or less turbid with degenerated cells and pus corpuscles. 
The intra-spinal processes of the pia mater are thickened and encroach 
upon the nervous substance of the cord. The nerve roots also exhibit 
signs of chronic inflammation and degeneration. 

Symptoms. The symptoms of chronic spinal meningitis differ only 
from those of acute meningitis by their more gradual development and 
by their lesser degree of intensity. The disease progresses without 
fever, and often exhibits successive periods of remission and exacerba- 
tion. The course of the disease may be protracted for many years. 
Recovery is possible, though permanent paralysis and muscular atrophy 
may involve many groups of muscles. Extension of the disease to the 
medulla oblongata is followed by a fatal result. Death is sometimes 



DISEASES OF THE SPINAL MENINGES. 803 

occasioned by the development of bedsores, or by cystitis and ammoni- 
semia. The treatment should be the same as that for acute myelitis. 

Spinal Meningeal Hemorrhage — Haemorrhagia Meningelis Spinalis. 

Meniyigeal hemorrhage is frequently caused by diseases of the spi- 
nal column, or of the structures within the spinal canal. It may 
also result from the rupture of an aneurism, or from a hemorrhage 
within the cranium from which blood has found its way into the spinal 
canal. It is not uncommon as a consequence of convulsions and spas- 
modic diseases that terminate fatally, and it may occur by reason of 
stagnation of the blood, or in connection with infective diseases when 
they assume a hemorrhagic character. The seat of hemorrhage is 
usually in the loose peri-dural connective tissue between the bony walls 
of the spinal canal and the dura mater (epi-dural hemorrhage). It 
may occur within the cavity between the dura mater and the arachnoid 
membrane (sub-dural hemorrhage), or it may occupy the sub-arachnoid 
space where the normal cerebro-spinal fluid lies (sub-arachnoid hemor- 
rhage). 

Symptoms and Diagnosis. Consciousness remains unaffected in 
cases of spinal meningeal hemorrhage. There is complaint of sudden 
localized pain in the spine, with girdle sensations, and neuralgiform 
pains in the body or extremities, according to the seat of hemorrhage. 
The spinous processes are not sensitive to pressure, but there is a feeling 
of stiffness in the muscles of the back or of the neck, if the hemor- 
rhage be high up. The usual symptoms of irritation of the sensory 
nerve roots are followed, after a time, by motor and sensory paralysis 
as pressure increases within the spinal canal. If the disease be suffi- 
ciently prolonged, the muscles become atrophied, and exhibit the reac- 
tion of degeneration. The reflexes disappear, the bladder and rectum 
become paralyzed, cystitis and bedsores may be developed. The 
disease may continue from two to eight weeks, or longer, though death 
sometimes occurs from shock at a very early period. If the region of 
the medulla oblongata be invaded, the characteristic disturbances of 
circulation, respiration, and pneumogastric function appear. Some- 
times meningitis is excited. 

Prognosis and Treatment. The prognosis is comparatively favor- 
able, since recovery not unfrequently occurs when the medulla ob- 
longata escapes injury. The treatment should be the same as that 
which will be described under the head of spinal hemorrhage. 

Tumors of the Spinal Meninges — Neoplasmata Meningealia. 

Every variety of neoplasm may be developed in connection with the 
spinal meninges, either as a primary disease or as a secondary manifes- 
tation of malignant disease in other parts of the body. Tumors may be 
connected with any one of the spinal membranes, though usually 
attached to the dura mater. They are usually of an oval form, and 
their dimensions are extremely variable. 



804 DISEASES OF THE SPIXAL COED AND MEMBRANES. 

Symptoms. The symptoms of meningeal tumors are excited by 
pressure upon the nerve roots, and upon the substance of the cord. 
Secondary symptoms may result from inflammation and degeneration 
of those structures. Non-malignant tumors frequently develop slowly 
and persist for many years. Death may result from exhaustion, or as 
a consequence of paralytic and degenerative changes which are 
secondary consequences of the growth of the neoplasm. 

Diagnosis. There is no pathognomonic symptom of a meningeal 
tumor. The existence of such a growth may be suspected, when malig- 
nant disease in other parts of the body, or when syphilitic or tubercular 
processes elsewhere, are succeeded by the symptoms of progressive irri- 
tation of the spinal nerves and compression of the cord. The situation 
of the neoplasm may be readily determined by the level below which 
painful and paresthetic symptoms are principally developed. The 
prognosis is usually unfavorable, though surgical interference has 
recently been attempted, with a favorable result. 



CHAPTER III. 

FUNCTIONAL DISEASES OF THE SPINAL CORD. 

Spinal Irritation — Irritation Spinalis. 

Symptoms. Spinal irritation is indicated by pain in the spinal 
column, neuralgiform pains in the skin and viscera, vasomotor and 
secretory disturbances, and muscular debility, sometimes associated with 
functional disorder of the brain, without any organic changes in the 
nervous structures. The disease is not unfrequently the result of anaemia, 
exhaustion, or cerebral weakness. The most constant symptom is pain, 
which usually occupies the dorsal vertebrae, though it may involve the 
whole length of the spine. It is greatly aggravated by pressure on the 
spinous processes, or by the application of a hot sponge or the galvanic 
current. The symptoms of irritation in the peripheral nerves may be 
exhibited in any portion of the body, or in the head ; and consist 
chiefly of sensory paresthesia associated with difficult and painful 
function in any one or all of the viscera. Vasomotor changes, mus- 
cular weakness, and spasm are common incidents. The disease is 
never attended with danger, though it may render life miserable for 
many years. For its successful treatment all causes of mental and 
bodily fatigue or anxiety must be removed. An abundance of nourish- 
ing and digestible food must be supplied ; the patient should live in the 
open air, obtaining sufficient bodily exercise upon the seashore, or in 
some healthy mountainous retreat to which the dissipation and worry 
of active life cannot find access. Debilitated patients who are unable 
thus to avail themselves of the privileges of a return to childhood, may 
be greatly benefited by removal from home, compulsory feeding, and 
massage, after the manner employed with such ability by Weir Mitchell 



FUNCTIONAL DISEASES OF THE SPINAL CORD. 805 

and his pupils. Iron, quinine, and cod-liver oil are of service in cases 
of anaemia, and galvanism should be applied daily with gentle currents 
along the spine. Nervines and tonics afford temporary and partial 
relief. 

Acute Ascending Spinal Paralysis — Paralysis Ascendens Acuta. 

Etiology. This rare disease (Landry's paralysis) is more frequent 
among men than among women, and is usually encountered during 
middle life. Its causes are unknown, though it is probably dependent 
upon an unrecognized contagion, since the course of the disease, the 
accompanying enlargement of the spleen, and swelling of the intesti- 
nal lymph follicles and mesenteric lymph glands, together with the 
absence of characteristic lesions in the nervous system, indicate the 
probability of some form of infection. 

Symptoms. The disease is frequently ushered in by fever, and soon 
presents the phenomena of a rapidly progressive ascending spinal 
paralysis. It begins in the feet, invades the muscles of the legs, thighs, 
loins, abdomen, back, and thorax ; then involves the muscles of the 
hands, forearm, upper arm, neck, throat, and face. Spastic symptoms 
do not appear, and the paralyzed muscles are completely flaccid. The 
patient is soon confined to bed, and is speedily deprived of the power of 
motion. Inspiration becomes difficult, and the accessory expiratory 
muscles fail. Deglutition and speech become more and more difficult, 
food and liquids regurgitate through the nasal passages, the pulse is en- 
feebled and accelerated, and death is preceded by the symptoms of 
asphyxia. During the whole course of the disease the electrical reac- 
tions of the paralyzed muscles remain unchanged. Cutaneous sensi- 
bility is but slightly modified, and trophic disorders are not developed. 
The bladder and rectum preserve their functions, though emptied with 
considerable difficulity, by reason of the paralytic condition of the ab- 
dominal muscles. The reflexes gradually disappear. Typical cases 
run their course without fever. Enlargement of the spleen and albu- 
minuria are commonly observed. Consciousness is maintained through 
the whole course of the disease. 

Death usually occurs during the second week, though life may be 
terminated within two or three days, or it may be prolonged for many 
weeks ; the fatal result is usually caused by bulbar paralysis. Re- 
covery occasionally happens, though convalescence is very tedious, and 
is often interrupted by relapses which may lead to a fatal termination. 

Diagnosis. Ascending myelitis, with which acute ascending paral- 
ysis may be confounded, differs by the presence of fever ; disturbances of 
sensation ; paralysis of the muscles, bladder, and rectum ; bedsores ; and 
loss of electrical excitability. All forms of poliomyelitis exhibit rapid 
wasting of the muscles and loss of electrical excitability. Acute poly- 
neuritis is attended by serious disturbances of sensation and by the 
rapid disappearance of electrical reaction in the nerves and muscles 
that are paralyzed. 

Treatment. Since syphilis sometimes precedes the disease, an 
active course of mercurial inunction, with iodide of potassium inter- 



806 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

nally, should be employed. Counter-irritants may be applied to the 
spine, and weak galvanic currents should be employed for five minutes 
each day. Our ignorance of the nature and causes of the disease ren- 
ders rational treatment impossible, and it becomes necessary to attempt 
the relief of symptoms only, as they arise. 

Reflex paralysis. Reflex paralysis is a term that has been applied 
to certain cases of paralysis associated with peripheral diseases, usually 
involving the intestinal tract or the urogenital apparatus. Similar 
cases have also been observed in connection with gunshot wounds of 
the nerves, diseases of the joints, and as a consequence of exposure to 
cold. The discovery of the fact that peripheral neuritis may follow an 
ascending course and may lead to inflammatory conditions of the spinal 
cord has deprived these cases of much of their former characteristic 
importance. It is probable that in the majority of so-called reflex 
paralyses they are dependent upon actual changes of an inflammatory 
and degenerative character, involving the peripheral nerves and their 
spinal connections. In the small minority of cases which cannot be 
thus explained it is probable that changes of structure exist which are 
not yet recognizable by the present methods of research. 

Psychic spinal paralysis. Spinal paralysis sometimes follows the 
occurrence of intense mental excitement, fright, grief, and shock. In 
such cases the bladder and rectum remain unharmed, but sensory dis- 
turbances are usually observed, together with a greater or less degree of 
muscular weakness or paralysis. The disorder is functional in its char- 
acter, and is relieved by rest, massage, electricity, restoratives, and tonics. 

"Writer's Cramp. 

Etiology. Writer s cramp usually occurs during middle life, 
among men of a delicately organized constitution who have been ex- 
hausted by overwork, poverty, dissipation, or misfortune, and whose 
occupation requires excessive effort in the coordination of the smaller 
and weaker muscles of the extremities. The disease is frequently 
termed professional cramp, since it is not confined to writers, but is 
encountered among all classes of workmen who occupy much time in 
the manner already described. It is commonly observed among clerks, 
musicians, watchmakers, tailors, shoemakers, weavers, and others 
whose occupation requires constant coordination of the delicate muscles. 

Symptoms. The symptoms of the disease are gradually developed 
in the smaller muscles of the hand, and in the extensors and flexors of 
the forearm. The muscles of the upper arm, shoulder, and neck may 
also participate in the disorder. 

Three varieties of the disease may be distinguished : a spastic, a 
tremulous, and a paralytic form. The spastic variety is most common. 
The paralytic form is least frequently observed. 

Spastic writer s cramp is characterized by tonic, and occasionally, by 
clonic muscular spasms involving the muscles of the fingers and 
thumb, rendering it difficult or impossible to use the pen. The spas- 



FUNCTIONAL DISEASES OF THE SPINAL CORD. 807 

modic or tremulous form of the disease is characterized by muscular 
tremors which occur during the act of writing, and render the script 
more or less illegible. The paralytic form of the disease is character- 
ized by a sense of fatigue in the affected muscles, and by the impossi- 
bility of executing necessary movements. 

Writer's cramp is aggravated by all forms of mental excitement as 
well as by convergence of the attention upon the disorder. Generally, 
muscular power is not affected, and the muscles of the hand are not 
enfeebled. Their capacity for ordinary movement and exertion in any 
other occupation than that of writing remains unchanged. Their elec- 
trical excitability generally remains unmodified, though the nerves with 
which they are connected sometimes exhibit a reversal of the ordinary 
galvanic reactions. In certain cases spasmodic disturbances invade 
other groups of muscles, and squinting, stuttering, and similar disorders 
may exist. Sensory disturbances and perversions may be developed, 
and in certain cases vasomotor derangement has been witnessed. 

Little or nothing is known regarding the anatomical basis of 
writer's cramp. The diagnosis of the disease is easy ; its prognosis 
is unfavorable, since relapses are frequent, even after a considerable 
period of rest. Even though the patient may have laboriously acquired 
the art of writing with the other hand, the disease soon invades its 
muscles, and his condition is as bad as ever. 

Treatment. Complete rest of the wearied muscles is necessary for 
a long period of time. Every effort must be made to invigorate the 
constitution, and to improve the general health. The effects of inju- 
ries or of local inflammations involving the nerves must be removed. 
A moderate galvanic current should be applied to the spine for five 
minutes every day. Tonic forms of the disease may be benefited by 
application of the galvanic anode to the affected muscles, while in par- 
alytic and tremulous forms the cathode should be similarly applied, or 
the faradic current may be employed ; though obviously that should 
not be applied to the muscles in spastic forms of the disease. Great 
benefit may be obtained from skilful massage. The usual methods of 
counter-irritation and friction with liniments, etc., are of comparatively 
little value. Temporary benefit is sometimes derived from the use of 
thick -stalked pens or other mechanical contrivances. 

Tetany. 

Etiology. Tetany is characterized by the paroxysmal occurrence 
of tonic muscular spasms involving particular muscular groups, and 
associated with an increase of the mechanical and electrical excitability 
of their motor nerves. It occurs most frequently among children and 
young people, especially those who are endowed with a rachitic and 
enfeebled constitution. It is frequently excited by exposure to cold and 
by other ordinary causes of nervous disease. It sometimes occurs 
endemically in boarding-schools and other similar collections of people, 
and it is more common in certain territorial localities than in others. 

Symptoms. The spasmodic paroxysms of tetany are usually pre- 
ceded by parcesthetic sensations in the extremities, and, in certain cases, 



808 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

by dizziness and other cerebral disorders of sensation. The spasms 
are bilateral and are usually limited to the flexor muscles of the fmsrers 

•J o 

and hand, though they may extend to the flexors and adductors of the 
whole extremity. In like manner the corresponding groups of the 
lower extremities may be affected. In certain instances the muscles of 
the body may be involved, and in the severest form of the disease the 
muscles of the head, face, eyes, tongue, pharynx, larnyx, and diaphragm 
may participate in the spasm. The fingers and thumb, during the 
spasm, are drawn together into a characteristically conical form, and 
the great toe is forcibly flexed and adducted under the other toes. 
Occasionally the extensor and abductor muscles are affected, so that the 
fingers and toes are spread apart. The muscles are slightly sensitive 
to pressure, and fibrillary contractions are visible through the skin. The 
period of spasm is frequently accompanied by various painful sensations 
and by disorder of the special senses. 

Spasmodic paroxysms may be very easily excited by compression of 
the muscles of an extremity with a bandage, or by pressure upon an 
artery in the limb. In this way latent forms of the disease may some- 
times be unmasked. The electrical excitability of the motor nerves is 
also exaggerated, so that weak faradic currents produce muscular con- 
tractions; and the application of weak, galvanic currents produces 
excessive contraction. The inordinate excitability of the motor nerves 
by mechanical irritation can be readily demonstrated by tapping the 
nerve trunks with the finger or with a percussion hammer. The ex- 
traordinary excitability of the facial nerve may be easily demonstrated 
by drawing the finger rapidly over the skin between the eye and ear, 
so as to make pressure upon the principal branches of the nerve. The 
muscles themselves do not exhibit any increase of excitability on direct 
mechanical irritation. 

Cutaneous sensibility is not particularly changed. Painful pressure- 
points exist along the spinal column. The general health is not seri- 
ously injured, though dyspeptic difficulties and intestinal disorders, 
with their usual consequences, are generally present. The duration of 
single paroxysms of the disease may vary from a few seconds to many 
hours, or even two or three days ; and the frequency of the paroxysms 
is equally variable. 

The disease usually terminates in recovery, though death occasionally 
results with convulsive phenomena, or it may occur as a consequence of 
exhausting diarrhoea. 

Tetany is a functional disease, since the trifling hemorrhagic effusions 
and other irregular pathological appearances which have been observed 
in the spinal cord are merely the accidental consequences of convulsion, 
rather than causes of the disease. It is probably a spinal disorder of a 
functional character, conditioned by an increased irritability of the 
ganglionic cells in the anterior cornua. 

Diagnosis. Tetany can be differentiated from tetanus, which be- 
gins with symptoms of trismus, a symptom that is absent in tetany. 
Hysterical convulsions do not exhibit the characteristic excitability of 
the nerves that is observed in tetany. The spasms which are observed 



FUNCTIONAL DISEASES OF THE SPINAL CORD. 809 

as a consequence of ergotism closely resembles the disease, but may be 
differentiated by reference to their cause. 

Treatment. The treatment of tetany should be chiefly guided by 
reference to its causes. Dyspeptic disorders and the presence of para- 
sites require particular attention to the condition of the alimentary 
canal. Cases associated with prolonged lactation, or other causes of 
exhaustion, require appropriate measures for their relief. Rheumatic 
patients should be treated with salicylic acid, iodide of potassium, and 
hot-air baths. Suppression of the menses or of hemorrhoidal discharges 
requires the application of cups and leeches, together with hot foot- 
baths. The paroxysms may be relieved by the administration of bromide 
of potassium, chloral hydrate, and ethereal remedies. Valerianate of 
ammonia, opiates, and other nervines are frequently administered ; but 
the principal attention must be given to the patient during the intervals 
between the paroxysms, when the application of gentle galvanic currents 
along the spine is of great benefit. 

Congenital Myotonia — Myotonia Congenita. 

Etiology. Congenital my otonia (Thomsen's disease) is characterized 
by a painless, tonic contraction of the voluntary muscles which persists 
for several seconds after they have been in any way excited to action, 
and consequently interferes considerably with the locomotion of the 
limbs. It is a disease which exists as an hereditary disorder in certain 
families. 

Symptoms. The symptoms of the disease are manifested in the 
territory of the voluntary muscles, usually in those of the lower ex- 
tremities, though all of the other voluntary muscles may be involved. 
It becomes impossible for the patient to perform rapid movements ; the 
hand that is clasped around the barrel of a gun, or any other object, 
cannot be immediately relaxed. If the patient is directed to open the 
mouth, several seconds elapse before the movement can be executed. 
Electrical excitation of the muscles does not exhibit any increase of 
irritability, but the muscular spasm which follows their contraction per- 
sists from ten to thirty seconds before relaxation follows. The motor 
nerves react normally to both faradic and galvanic currents. Mechani- 
cal irritability of the motor nerves is diminished, while that of the 
muscles is increased. 

The symptoms are increased in severity by excitement, fatigue, ex- 
posure to cold, and feverish conditions ; but they are diminished by 
moderate exercise, warmth, and the use of alcohol. The disease con- 
tinues during the whole of life, and is unattended by any danger. 

The muscular fibres are increased in size, the nuclei of the sarcolemma 
are increased in number, and the muscular substance itself exhibits 
vacuolation and considerable obliteration of its striae. The interstitial 
connective tissue is slightly increased. Still it is probable that the 
disease is of central origin, since it is frequently associated with spasms 
and spinal symptoms which may be aggravated by cerebral excitement. 

The disease may be distinguished from muscular hypertrophy by 
the presence of modifications of mechanical and electrical irritability, as 



810 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

well as by the persistence of voluntary muscular contraction, circum- 
stances that are not observed in the hypertrophic disease. 

Treatment. Gymnastic exercises, massage, baths, and electricity 
afford the only known means of relief. Internal remedies exert no in- 
fluence upon the disease. 

Paramyoclonus Multiplex. 

This disease is characterized by paroxysms of clonic spasm, usually 
involving symmetrical muscles, without otherwise influencing their nu- 
trition, their mechanical or electrical excitability, their strength, or their 
power of coordination. The electrical reactions of the motor nerves are 
also normal. The disease is usually observed among hysterical or 
nervous persons who have suffered from fright, or from other depressing 
causes. The muscular contractions follow one another fifty or sixty 
times in a minute, or even oftener. In certain cases one muscle only 
is involved in the spasm, while in other cases groups of muscles may 
be affected. When the diaphragm and other abdominal muscles are 
involved, a noisy, panting respiration is audible, like that of a dog after 
running Sensory disturbances are generally absent. The reflexes 
are either unchanged or slightly increased. The disease is unattended 
with danger, and generally yields to galvanization of the spinal cord. 



CHAPTER IV. 

UNSYSTEMATIZED DISEASES OF THE SPIXAL COED. 

Spinal anaemia may be produced by local conditions which interfere 
with the circulation of the blood within the cord, or it may be the result 
of hemorrhage, of wasting discharges, and of chlorotic and anaemic con- 
ditions that affect the general circulation. Under such circumstances, 
the spinal vessels are imperfectly filled, and the nutrition of the gan- 
glionic cells and nerve fibres is deteriorated. The functions of the 
cord are reduced in vigor, and in severe cases may be more or less 
completely abolished. In chronic cases which depend upon impoverish- 
ment of the blood, muscular power is reduced, sensation may be either 
exalted, modified, or wholly abolished, and the reflexes are exaggerated. 
The indications for treatment point to the adoption of such measures as 
will increase the quantity and quality of the blood, and will improve 
the circulation. 

Spinal hyperaemia is usually associated with a hyperaemic condition 
of the spinal meninges. It may be either active or passive. The first 
form is encountered as a consequence of exposure to cold, concussion, in- 
flammation, excessive muscular exertion, infective disease, menstrual or 
hemorrhoidal suppression, and poisoning with carbonic oxide, alcohol, 
strychnine, etc. 



UNSYSTEMATIZED DISEASES OF THE SPINAL CORD. 811 

Passive hyperemia of the spinal cord exists in connection with 
the general stagnation of the blood that accompanies cardiac and pul- 
monary or abdominal diseases. 

Spinal hyperemia occasions feelings of pressure, tension, and pain in 
the spinal region. Hyperesthesia, paresthesia, local spasms, exalted re- 
flex irritability, and increased galvanic excitability occur without the 
development of fever. The symptoms are subject to rapid variation, 
and are frequently overlooked in consequence of their association with 
symptoms of cerebral hyperaemia. 

The indications for treatment call for the employment of vigorous 
counter-irritation with cups along the spinal column, leeches at the 
anus, and hot mustard foot-baths. The bowels must be kept freely 
open ; the diet must be moderate and unstimulating. Hydropathy is 
frequently of great service. Ergot and belladonna may be administered 
internally by those who have confidence in their efficacy. 

Spinal Hemorrhage — Haemorrhagia Medullae Spinalis. 

Etiology. Primary spinal hemorrhage is caused by injuries, by 
exposure to cold, by excessive excitement, and muscular exertion, by 
stagnation of blood in consequence of diseases of the heart, lungs, or 
liver, and by previous diseases of the spinal cord or of its neighboring 
structures. 

Secondary hemorrhage is generally dependent upon previous in- 
flammation of the spinal cord. • 

Pathological Anatomy. — Hemorrhage usually occurs in the cer- 
vical or dorsal portions of the cord. It generally involves the anterior 
cornua and occupies a circumscribed space within the substance of the 
cord. Sometimes blood finds its way, for a considerable distance, between 
the bundles of nerve fibres, but this is unusual. In recent cases the 
blood is clotted, and the neighboring tissue is softened and stained by 
inflammation. In old cases the clot is encapsulated by proliferation of 
the connective tissue, which transforms the hemorrhagic effusion into 
a cyst-like cavity, the so-called apoplectic cyst. After slight hemorrhage 
a simple pigmented mass of cicatricial tissue remains when the blood 
has been removed by absorption. 

Spinal hemorrhage is frequently followed by changes in the me- 
ninges, and by inflammation and secondary degeneration in the cord 
itself. 

Symptoms and Diagnosis. A sudden hemorrhage is followed by 
the immediate development of paralysis, which varies according to the 
level and extent of effusion. In the majority of cases the symptoms 
indicate complete destruction of the functions below the seat of lesion, 
but in certain cases only one-half of the cord appears to be involved, 
or a limited group of cells, usually those in the anterior cornua, give 
signs of paralysis. 

The disease is usually ushered in by severe pain at the point of 
hemorrhage. Paralysis is immediately developed, usually in the lower 
extremities (paraplegia), though occasionally involving both extremities 



812 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

upon the same side (spinal hemiplegia), or only one limb (monoplegia). 
The nerves of sensation and the bladder and rectum are also paralyzed, 
and the muscles are flaccid. The reflexes are at first more or less com- 
pletely abolished, but after a time they may reappear, and they exhibit 
considerable exaggeration when the hemorrhagic effusion is situated 
above the lumbar portion of the cord. The paralyzed muscles become 
rapidly atrophied, and the reaction of degeneration is developed when 
the anterior cornua are destroyed. Involuntary spasms frequently 
occur in the muscles of the lower extremities when the lumbar portion 
of the cord is not involved in the lesion. Vasomotor and trophic dis- 
turbances are rapidly developed in the paralyzed extremities, and blood 
and albumin frequently appear in the urine. Consciousness is not affected 
unless the phenomena of shock are developed. Fever rarely ever oc- 
curs, unless cystitis and bedsores complicate the case. Death may 
result very speedily when the hemorrhage is seated in the upper portion 
of the cord. Paralysis of the plirenic nerves and dyspnoea are occasioned 
by hemorrhage at the level of the fourth and fifth cervical nerves. In 
many cases death results at a late period in consequence of bedsores 
and septic poisoning, or by reason of the development of cystitis and 
ammoniacal decomposition of the urine. 

Prognosis. The prospect of recovery is very unfavorable for, though 
life may not be destroyed, the process of cicatrization is followed by 
permanent paralysis and contracture of the affected muscles. 

Treatment. In cases attended by the symptoms of spinal hyper- 
emia, cups should be applied to the back, and leeches to the anus. The 
diet must be simple and unstimulating ; the bowels must be relieved 
each day. Chapman's spinal ice-bags should be applied to the spinal 
column, in order to effect a permanent reduction of temperature and 
contraction of the bloodvessels at the seat of hemorrhage. Iodide of 
potassium should be given in five-grain doses three times a day, to pro- 
mote absorption. After about two months, when all acute symptoms 
have disappeared, the galvanic current may be applied in alternate 
directions along the spinal cord for ten minutes every other day. The 
back should be sponged with alcohol several times a day, and if any 
indications of the formation of bedsores make their appearance, the 
patient should lie upon a water-bed. 

Acute Inflammation of the Spinal Cord — Myelitis Acuta. 

Etiology. Acute myelitis is more frequent among men than among 
women, and is usually encountered during middle life. The primary 
form of the disease is excited by exposure to cold and damp (rheumatic 
myelitis). It frequently results from injuries, and from the suppression 
of menstrual or hemorrhoidal effusions. It has been ascribed to severe 
mental excitement, and to excessive debauchery, but in many cases no 
apparent cause for the disease can be discovered. 

Secondary myelitis is frequently dependent upon previous diseases 
of the spinal column or meninges. It is a usual consequence of com- 
pression of the cord, and it may result from previous diseases of the 
spinal cord itself, or from the extension of migratory neuritis to the 



UNSYSTEMATIZED DISEASES OF THE SPINAL CORD. 813 

cord. It is not uncommonly observed as a complication of the infective 
diseases and of chronic wasting disorders. 

Pathological Anatomy. Acute myelitis commences in the vessels 
and neuroglia, or in the connective tissue, and extends rapidly to the 
nervous elements themselves. It generally attacks the dorsal portion 
of the cord before invading the cervical and lumbar regions. The gray 
matter in the majority of cases first undergoes inflammation, which 
may remain thus circumscribed, or may finally extend into the white 
substance of the cord. The whole diameter of the cord is sometimes 
invaded, but in certain cases the seat of inflammation may occupy only 
one-half of its section. It may occupy a considerable extent of the 
cord, or it may be disseminated in the form of inflammatory islets that 
are surrounded by healthy tissue. Cases have been observed in which 
the peripheral portion of the cord was alone inflamed, though such cases 
are usually associated with inflammatory conditions of the spinal 
meninges. 

The portion of the cord that is occupied by inflammation becomes 
softened, though softening alone affords no indication of inflammation, 
since it may be the result of post-mortem changes. In recent or acute 
cases the softened portions of the cord are reddened by excessive dis- 
tention of the bloodvessels and by hemorrhagic effusions. As the pro- 
cesses of absorption and fatty degeneration of the products of in- 
flammation proceed, the softened portion assumes a yellowish color, 
which finally becomes gray in consequence of the deposit of pigment 
in the cicatricial tissues. At the last stage of the disease, secondary 
inflammation may proceed upward and downward from the original seat 
of inflammatory action. 

Microscopical examination indicates the occurrence of inflammation 
in the vascular walls ; the lymph channels contain red and white blood- 
corpuscles ; the neuroglia exhibits evidence of proliferation ; the medul- 
lary sheaths of the axis-cylinders are broken up, undergo granular de- 
generation, and disappear. The axis-cylinders themselves swell and 
exhibit nodular changes of form. They lose their normal fibrillar 
structure, become vacuolated, undergo granular degeneration, and dis- 
appear. The ganglionic cells lose their characteristic fibrillary and 
granular structure, become vacuolated and deprived of their processes. 
Their nuclei become indistinct, and frequently undergo subdivision. 
Fatty degeneration and disappearance of the entire structure finally 
occur. The diseased cells become deeply pigmented, and, if not totally 
destroyed, are transformed into small globular masses that are destitute 
of processes. Numerous white blood-corpuscles, or wandering cells, 
distended with fat globules make their appearance. They are probably 
connected with the function of absorption, and gather up the fatty 
debris of the tissues for transportation into the lymph-vessels. Certain 
amyloid bodies which resemble grains of starch also become visible, but 
nothing is known regarding their nature. The lymph-vessels and 
spaces are frequently occupied by a colloid substance which appears to 
be coagulated exudation. Broken-down red blood-corpuscles and crys- 
tallized or amorphous masses of blood pigment are strewed at random 
over the field of observation. 



814 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

The membranes of the cord and of the spinal nerve roots usually 
participate in the inflammatory process. The corresponding peripheral 
nerves and muscles also exhibit signs of degeneration. Bedsores form 
in consequence of inflammation in the posterior cornua, and the urinary 
passages become inflamed, giving occasion for ammoniacal decomposi- 
tion of the urine. 

In certain very rare cases, actual suppuration of the spinal cord has 
been discovered as a consequence of acute myelitis. Occasionally in- 
flammation is followed by the development of cysts within the substance 
of the cord. When the connective tissue undergoes extraordinary pro- 
liferation, the process has been described under the name myelitis hyper- 
plastic a. In many cases inflammation subsides into a chronic form, 
accompanied by the development of chronic sclerosis, characterized by 
atrophy of the nervous elements and by predominance of the connective 
tissue. 

Symptoms. Acute myelitis is usually developed rapidly, with the 
symptoms of fever which, in children, may be ushered in by convul- 
sions. Sensations of formication, numbness, fatigue, and shooting 
pain, are frequently accompanied by retention of the urine. Pain is 
experienced in that portion of the spinal column which corresponds to 
the seat of the disease. It is frequently aggravated by movement, or 
by pressure upon the spine, or by the application of hot sponges or 
galvanism over the backbone. A sense of constriction is often experi- 
enced, as if some portion of the body were surrounded by a tight band 
corresponding to the irritated sensory nerve roots at the level of the in- 
flammation. At the commencement of the disease, besides pain and 
cutaneous hyperesthesia, muscular spasms and contracture are fre- 
quently observed before the development of paralytic symptoms. In cer- 
tain cases severe pain is experienced after the occurrence of complete 
motor and sensory paralysis (anaesthesia dolorosa). 

Flaccid paralysis of the muscles corresponds to the situation and ex- 
tent of the spinal lesion. At first the muscles appear unchanged, but 
after a time they become wasted from disease ; and if the trophic cells 
in the anterior cornua are destroyed, or if the anterior nerve roots are 
invaded, muscular degeneration occurs. The electrical reactions exhibit 
corresponding changes. 

Cutaneous sensibility diminishes and finally disappears. Retarded 
conduction of impressions, and other disturbances of sensation, some- 
times accompany the progressive reduction of sensibility. Vasomotor 
and trophic disturbances are also developed. The paralyzed limbs are 
at first warmer and more highly colored than usual, but subsequently 
they become pale and cold. The epidermis exfoliates, and bedsores 
appear over the sacrum and over other bony prominences in the lower 
extremities. Extensive inflammation of the lower portion of the spinal 
cord occasions the disappearance of the reflexes. When the lesion is 
situated at a higher level, the reflexes in the lower extremities are ex- 
aggerated. The urine becomes bloody, albuminous, turbid, and ammo- 
niacal. The bladder and rectum are completely paralyzed when the 
lumbar portion of the cord is involved. Urine may be retained by 
reason of paralysis of the detrusor muscle, or it may dribble away in 



UNSYSTEMATIZED DISEASES OF THE SPINAL CORD. 815 

consequence of paralysis of the sphincter muscle. When both muscles 
are paralyzed, continual dribbling may occur from the over-filled 
bladder. In like manner, constipation of the bowels may be succeeded 
by involuntary evacuations. Inflammation of the upper portion of the 
dorsal division of the cord is frequently accompanied by the occurrence 
of priapism. 

Diagnosis. Myelitis may be distinguished from acute spinal menin- 
gitis by the fact that in the meningeal disease symptoms of paralysis 
are less conspicuous, and the evidences of pain on movement of the 
spinal column are excessive. Hemorrhage of the spinal cord and 
meninges is suddenly developed, and is unattended by symptoms of 
irritation. Landry's acute ascending paralysis closely resembles ascend- 
ing myelitis, but is characterized by more rapid progress, and by the 
absence of change in the electrical reactions. In cases of multiple neu- 
ritis electrical excitability of the paralyzed muscles and nerves rapidly 
disappears. Hysterical paralysis is usually observed in women, and is 
accompanied by other symptoms of hysteria. 

Prognosis. The course of acute myelitis is exceedingly variable. It 
may assume a rapid and violent form, speedily terminating in death, or 
it may linger for weeks and months. In many cases the consequences 
of the disease are permanent. Complete recovery is scarcely ever 
observed. 

Treatment. When acute myelitis is dependent upon syphilis it 
should be actively treated with daily inunctions of mercurial oint- 
ment and the use of iodide of potassium, in five-grain doses three times 
a day. This should be continued for six or eight weeks, and then, after 
an intermission of a month, a second course of inunction should be in- 
stituted. In many cases two or three such repetitions may be recom- 
mended. Even in non- syphilitic cases this method often gives the best 
results. 

When menstrual or hemorrhoidal suppression has preceded the dis- 
ease, leeches and cups should be applied over the sacrum. 

The diet must be simple and unexciting. Great attention must be 
given to the condition of the bed, and the position of the patient should 
be changed several times each day, so as to avoid the effects of 
pressure. The back should be rubbed with alcohol, and if any 
portion of the skin becomes reddened by pressure, it must be pro- 
tected by the application of adhesive plaster, and a water-bed 
should be procured. If bedsores form, they should be antisepti- 
cally dressed, in accordance with the rules of surgery. The bladder 
must be emptied three times a day with a perfectly clean catheter. The 
effects of dribbling from the bladder must be obviated by the use of 
appropriate receivers for the urine, and the skin must be carefully 
cleansed in order to prevent bedsores. When ammoniacal decomposi- 
tion of the urine occurs, ten grains of salol may be prescribed every 
two hours, and the bladder should be irrigated every day. The bowels 
must be carefully regulated, and perfect cleanliness must be secured. 

Local treatment should consist at first in the application cf Chap- 
man's ice-bags to the spine. Their rubber surface should never be 
allowed to touch the skin, but must be separated from it by a layer of 



816 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

cloth, in order to prevent cutaneous inflammation. Chloroform lini- 
ment may be applied to the spine, but blisters and other counter- 
irritants should be avoided for fear of bedsores. 

For anaemic and enfeebled patients the syrup of iodide of iron may 
be prescribed. Hypodermic injections of morphine and atropine may 
be used when required for the relief of pain. 

After the subsidence of acute symptoms, nitrate of silver (one-fourth 
of a grain three times a day), chloride of gold and sodium (one-twelfth 
of a grain three times a day), strychnine (one-thirtieth of a grain three 
times a day), or Fowler's solution of arsenic (four drops three times a 
day), are of considerable service. The use of electricity may now be 
commenced ; the paralyzed muscles should be faradized, and weak gal- 
vanic currents may be applied to the spine for five minutes at a time 
every other day. 

During convalescence the patient must be warned against the evil 
effects of over- exertion. Moderately warm baths are useful, but they 
must be employed with great moderation in the matter of duration and 
frequency. 

Chronic Inflammation of the -Spinal Cord — Myelitis Chronica. 

The causes of chronic inflammation of the spinal cord are the same 
that produce acute inflammation. Why they should operate more 
rapidly in one case than in another is not clearly understood. 

Pathological Anatomy. Chronic myelitis often produces changes 
in the spinal cord that can be recognized only by the aid of the micro- 
scope. When visible changes exist they cause an increase in the 
density of the affected tissues, which also appear shrunken and of a 
gray color, by reason of an increased deposit of pigment. The seat of 
inflammation usually occupies the dorsal portion of the cord. When a 
limited portion is invaded it is termed circumscribed myelitis. When 
the whole diameter of the cord is inflamed it is termed transverse 
myelitis; and when isolated patches of inflammation are distributed at 
random in the cord, it is termed multiple or disseminated myelitis. 
When the gray matter alone is inflamed it is described as central 
myelitis. 

The microscopical appearances differ chiefly from those which are 
observed in acute myelitis by the greater proliferation of connective 
tissue and by the presence of amyloid bodies, while the fat-laden cells 
which are so conspicuous in acute inflammation are less frequently visible. 
The nerve roots are atrophied and sclerosed, and the muscles frequently 
exhibit the signs of degenerative atrophy. 

Inflammatory conditions are frequently observed in the urinary 
passages, kidneys, and lungs. 

Symptoms. In many cases chronic myelitis is the consequence of a 
subsiding attack of acute inflammation. In other cases it is gradually 
developed in a chronic form. It is frequently introduced by neuralgic 
pains, sensations of constriction around the body, various parsesthetic 
modifications of cutaneous sensation, and a gradual development of 
motor and sensory paralysis. 



UNSYSTEMATIZED DISEASES OF THE SPINAL CORD. 817 

Motor 'paralysis comes on gradually, with feelings of fatigue and 
rapid exhaustion after muscular movement. The lower extremities are 
no longer under the complete control of the will, and finally the power 
of locomotion is lost. Usually the disease attacks the lower extremities, 
and may after a time invade the upper extremities, life being terminated 
at last by paralysis of the bulbar nerves. The bladder and rectum are 
frequently paralyzed at an early stage of the disease. The reflexes 
and the electrical reactions of the nerves and muscles follow the same 
course that is observed in acute myelitis. In the later stages of the 
disease the paralyzed muscles become contractured, and the tendinous 
reflexes are exaggerated as the lateral columns of the cord are invaded 
by the disease. 

Exacerbations of the disease are not uncommon. Its duration may 
be protracted through a number of years. Intercurrent infective dis- 
eases sometimes exert a favorable influence upon the course of chronic 
myelitis, but complete recovery scarcely ever occurs. Death may result 
from exhaustion, septicaemia, amtnonisemia, or from the extension of the 
disease to the medulla oblongata. The treatment is the same that is 
prescribed for acute myelitis. 

Embolic and Thrombotic Softening of the Spinal Cord — Myelomalacia 
Embolica et Thrombotica. 

From those forms of softening which are dependent upon inflammation 
of the spinal cord, must be distinguished certain cases that are produced 
by obstruction of the spinal bloodvessels with emboli or thrombi. Care- 
ful examination of the bloodvessels is very necessary, in order to ascer- 
tain the nature of such softening, since the color and consistence of the 
affected portion depends upon the vascularity of the part, and upon the 
very variable amount of effusion and pigmentation that has accompanied 
the process. Considerable confusion may exist in consequence of the 
fact that inflammatory softening may produce thrombosis in the adjacent 
bloodvessels, while embolic or thrombotic softening may also excite a 
secondary inflammation in its immediate vicinity. Minute and circum- 
scribed lesions can exist without symptoms, but when the seat of disease 
involves any considerable portion of the cord, the symptoms of acute 
myelitis are developed. 

Multiple Cerebro-spinal Sclerosis — Sclerosis Cerebro-spinalis 

Multiplex. 

Etiology. Multiple cerebro-spinal sclerosis usually occurs during 
the first half of adult life. It is frequently encountered among mem- 
bers of neurotic families, and it is apparently excited by the ordinary 
causes of spinal inflammation. 

Pathological Anatomy. The disease consists in the formation of 
scattered centres of inflammation, which are irregularly distributed in 
the substance of the brain and spinal cord. Their number is exceed- 
ingly variable, and their size differs from that of a microscopical point 
to that of a mass measuring several inches in extent. They may be 

52 



* I S : : s z a s z s :• z rzz s?:xa: : . z : i\: :i is. 

generally recognized as salmon-colored tumors of a firmer consistency 
than that of the surronnding tissue S ometimes they protrude above 
the surface, but frequently the" mewhat retracted. Their form 

is often as irregular as their distribution. The floor of the fourth ven- 
tricle, the pons Varolii, the white substance of the brain around the 
cerebral ventricles, and the white substance of the spinal cord and 
cerebellum are the favorhr seals of development for these sclerotic 
masses The cerebral nerves and the spinal nerve roots are also often 
invaded. Sometimes the membranes of the cord exhibit evidences of 
circumscribed inflammation and adhesion. Those muscles which are in 
connection with portions of the cord that have become sclerosed un _ 
::: ir-iy m: ^^ir::.::::. 

M roscopieal examination reveals changes similar to those which 
occur in chronic myelitis. The interstitial connective tissue prolifr 
at the expense of the nervous elements. The axis-cylinders, though 
swelled and distorted, persist sometimes through the whole oour- e 
:i- i:sr3.se 

Symptoms. S« extensive z±& so irregular is the distribution of 
the islets of sclerosed tissue that a corresponding variety of symptoms 
is inevitable. In certain cases cerebral symptoms preponderate, in 
others spinal symptoms are most prominent, and their nature varies 
according to the seat of the most extensive and overwhelming le- 
since they are displayed by those external organs that are in communi- 
cation with the central foci of the dise&Sr 

Cerebrospinal sclerosis usually comiEr th vague and indefinite 

symptoms of pain, headache, dirainess, disordered digestion, and 
unusual fatigue after exertion. The lower limbs gradually become 
enfeebled, and the characteristic symptoms of the disease are developed. 
These consist in the occurrence of peculiar muscular agitation in con- 
nection with voluntary movement (volitional tremor), nystagmus, scan- 
ning speech, paresis, and apoplectiform am 

~~: itwnal tremor accompanies every voluntary exertion on the part 
of the patient. The attempt to carry a glass of water to the mouth 
usually results in spilling a considerable portion of the liquid. The 
: writing becomes almost impossible, and the chirography is char- 
acteristically illegible. These movements cease when the muscles are 
-.: -— :. 

. <tagmu* and the scanning pronunciation of words are. in like 
manner, dependent upon muscular tremor accompanying voluntary 
movements of the ocular and vocal muscles. The head also shakes 
when unsupported, and the movements of respiration exhibit a similar 
intermittent course when the patient is -ince. under such 

circumstances, muscular contraction assumes a somewhat voluntary 
character. 

pUctiform and, occasionally, epileptiform seizure* may occur 

during the course of the disease. They are frequently followed by 

symptoms of fever and by temporary paralysis which disap»pears in the 

•e of a few days. 

"itrbances of sensation are neither common nor conspicuous. In 

certain cases the phenomenon of allocheiria have been observed, thai 



UNSYSTEMATIZED DISEASES OF THE SPINAL CORD. 819 

sensory impressions upon one side of the body are erroneously referred 
to the other side. 

The muscles are enfeebled, but seldom undergo complete paralysis. 
Spasmodic contractions are sometimes observed, especially during vol- 
untary effort, and contractures are gradually developed in the muscles 
of the neck and in the lower limbs which are so strongly adducted and 
flexed as to render locomotion impossible. In certain cases the rigidity 
of the lower extremities produces a spastic gait like that which is 
observed in spastic spinal paralysis. When the posterior columns of 
the cord are affected, the ataxic symptoms of tabes dorsalis appear. 

The cutaneous and tendinous reflexes are generally exaggerated. A 
slight tap upon the tendons produces an excessive muscular response. 
Ankle clonus may be readily developed by suddenly pressing the foot 
into a position of extreme dorsal flexion. 

Paralysis of the bladder and rectum sometimes occurs, and may be 
accompanied by cystitis and all its dangerous consequences. 

Vasomotor and trophic disturbances are sometimes developed, and 
the electrical reactions are disordered. 

In certain cases the medulla oblongata is invaded by the disease and 
the nuclei of the bulbar nerves become sclerosed. The phenomena of 
bulbar paralysis then appear. Speech, deglutition, respiratory and 
cardiac movements are gradually disordered and paralyzed, and death 
may result from the intrusion of food into the larynx, or from other 
consequences of bulbar paralysis. 

When the other cerebral nerves are invaded by the disease, the 
special senses and ocular movements in like manner experience dis- 
order and progressive paralysis. More or less complete deafness, 
myosis, mydriasis, double vision, temporary blindness, and reduction of 
the visual field, not unfrequently occur. Spinal myosis is less common 
than in tabes dorsalis. 

There is frequent complaint of dizziness and vertigo which are often 
dependent upon diplopia. The emotional nature manifests serious 
changes, and many cases are finally merged in total insanity. 

The disease may persist for many years. Cases of thirty years' dura- 
tion have been recorded. Their course is frequently attended by alter- 
nate remissions and exacerbations, but recovery never occurs, and 
death results either from exhaustion, or during the course of an apo- 
plectiform attack, or as a consequence of bedsores, or bulbar paralysis, 
or by reason of some intercurrent disease. 

Diagnosis. The diseases with which multiple cerebro-spinal scle- 
rosis may be confounded are paralysis agitans, chorea, athetosis, and 
tremor from other causes. Paralysis agitans is a disease of old age, and 
differs in the fact of the persistence of tremor in muscles which are at 
rest. It is also diminished by voluntary effort. 

Chorea is characterized by the greater breadth and irregularity of 
muscular movements. It is usually a disease of children. 

Athetosis is characterized by the existence of paralysis and contrac- 
tures in the affected limbs ; and the movements are more gradually 
developed and more irregular than those which accompany sclerosis. 

Ordinary tremors are characterized by the very limited extent of 



820 DISEASES O* THE SPINAL CORD AND MEMBRANES. 

the muscular excursions, and by the fact that they may be generally 
referred to old age. cachexia, or alcoholic intoxication. 

In certain rare instances the symptoms of cerebro spinal sclerosis 
exhibit the characteristics of a purely functional disease unattended by 
any discoverable lesi ds in the spinal cord, while in other cases exten- 
sive lesions have been demonstrated after death, though the character- 
istic and pathognomonic symptoms had not been observed during life. 
r:imes the disease presents a remarkable likeness to the features 
of tabes dorsaUs. but a careful comparison of symptoms will usually 
reveal characteristic differences in the behavior of the pupils, and in 
the condition of the tendinous reflexes. I: is sometimes quite imj 
ble to avoid confusion of the disease with cases of js tresis 

oftJ.-. A ~ Ui il sclerosis also presents many points 

:: similarity, but it usually commences in the upper extreini:: — 

Treatment. The general treatment for chronic myelitis suffic- 
the majority of cases of cerebro-spinal sclerosis. Extension of the 
spinal column by suspension has sometimes r-n followed by partial 
improvers nt 

Tumors of the Spinal Cord — Neoplasmata Medullae Spinalis. 

Tumors involving the substance of the spinal cord are rarely ob- 
serve:!. They may reach considerable size without the appeami 
notable symptoms. In certain cases their growth occasions the phe- 
nomena of acute or chronic spinal disease without the occurrence of 
anything to indicate that such symptoms depend upon the existence of 
a tumor. Sometimes they occasion sudden hemorrhage and ec 
sponding consequences. According to the location of the disease will 
be the character of the symptoms, sometimes involving one or more of 
the columnar tracts of the cord, or in other cases indicating an in- 
d or compression of its total diameter. Occasionally the resulting 
nervous symptoms may be so closely connected with the function of 
other organs — for example, the respiratory apparatus — that their spinal 
origin is entirelv overlooked. 



■ -• 



Cavities in the Spinal Cord — Syringomyelia et Hydromyelia. 

s in the substance of the spinal cord are either congenital or 
of later origin. In certain cases they extend the whole length of the 
: in others they are circumscribed within very narrow limits, and 
their form exhibits great irregularity. Their contents usually consist 
of a clear, serous fluid that is rarely stained with blood or other con- 
stituents. The cavity is sometimes surroun \n imperfectly 
developed eupsuie. but in other cases it possesses no clearly defined 
boundarv. When a cavity has its origin in a dilatation of the central 
canal of the cord, it is lined with cylindrical epithelium. Its immediate 
vicinitv is often occupied by patches of inflammation : and sometimes 
the neighboring vertebrae are in a carious condition. 

Such cavities are frequently produced by dilatation of the central 
canal as a consequence of peri-ependymal sclerosis or other obstruction 



TRAUMATIC DISEASES OF THE SPINAL CORD. 



821 



of the circulation. In certain cases they result from the softening and 
reabsorption of tumors (gliomata), or of the products of inflammation. 
Meningeal adhesion frequently exists in their neighborhood. 



Fig. 15' 







Syringomyelia. Gangrene of the fingers. (Church.) 

The symptoms are exceedingly obscure, and in many cases entirely 
escape observation. In certain cases slowly progressive atrophy has 
been observed in the upper extremities, associated with profound modi- 
fications in the power of perceiving variations of temperature and im- 
pressions of pain. Vasomotor and trophic changes, involving the 
manifestation of cutaneous eruptions and symmetrical gangrene of the 
fingers and extremities (Morvan's disease), together with abolition of 
the tendinous reflexes, and the occasional development of muscular 
rigidity and contracture, have been described. (Fig. 157.) Bulbar 
paralysis not unfrequently terminates the course of the disease, which, 
in many respects, closely resembles certain of the phenomena of leprosy. 



CHAPTEE V 



TRAUMATIC DISEASES OF THE SPINAL CORD. 



Concussion of the Spinal Cord — Commotio Medullae Spinalis. 

Etiology. Concussion of the spinal cord has its origin in such 
forms of violence as affect its functions without producing palpable in- 
juries of the spinal column or meninges. It is frequently associated 
with the phenomena of shock, and is a common consequence of railway 



822 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

accidents and other violent commotions. There is often evident a great 
want of proportion between the nervous symptoms and the discoverable 
lesions; in short, the psychical phenomena frequently outweigh the phys- 
ical changes. For this reason the term traumatic neurosis seems particu- 
larly appropriate. Alcoholism, excessive use of tobacco, debauchery, 
hereditary influences, and the various predisposing causes of nervous 
disease, favor the occurrence of traumatic neurosis after comparatively 
slight injuries. The disease is sometimes developed as a consequence 
of the terror and excitement that accompany the anticipation of injury, 
even though an actual collision may have been averted. Such cases 
are occasionally observed among railway servants who have been thus 
exposed to imminent risk without actual bodily harm. 

Pathological Anatomy. In cases of early death after pure spinal 
concussion no visible changes can be discovered. Sometimes points of 
hemorrhage are visible in the spinal cord and in the meninges. At a 
later period the evidences of chronic meningitis, or myelitis, or of both 
diseases are sometimes apparent. 

Symptoms and Diagnosis. In certain cases the ordinary phe- 
nomena of shock are followed by speedy death ; in other instances 
convalescence is gradually established and results in complete recovery ; 
while in a third class of cases recovery occurs only after many months. 

Sometimes an injury is followed by no conspicuous symptoms, and 
the patient congratulates himself upon his fortunate escape ; but after a 
variable period of time the evidences of spinal irritation or of paralysis 
are gradually developed. Thus may be originated various forms of 
spinal disease which resemble chronic myelitis, multiple sclerosis, spastic 
paralysis, tabes dorsalis, and other spinal affections. The intellectual 
faculties sometimes give evidence of deterioration, and there is com- 
plaint of headache, insomnia, excessive debility, cardiac disturbance. 
and various psychical disorders. The eyes, in certain cases, exhibit 
optic atrophy and pupillary disturbances, or contraction of the visual 
field, and color blindness. 

Like other spinal diseases such cases follow a very tedious course, and 
sometimes are terminated by death. 

Prognosis. Excluding all cases of deception and malingering, the 
prognosis is unfavorable ; though patients of an hysterical temperament 
who have suffered spinal concussion may recover completely after some 
new and engrossing object of interest has engaged their attention. So 
long as the patient is oppressed by anxieties regarding the future, or 
regarding the settlement of claims for damages which may have been 
brought into the courts, the prospect for recovery is unfavorable, and it 
is vastly improved by the removal of all such forms of psychical agitation. 

Treatment. During the early stage of spinal concussion the treat- 
ment of shock must be instituted. Stimulants and restoratives may be 
freely administered. Traumatic neurosis may be treated with elec- 
tricity, massage, the rest-cure, and hydropathy. Inflammatory symp- 
toms require the treatment for acute or chronic myelitis. 



TRAUMATIC DISEASES OF THE SPINAL CORD. 823 

Compression of the Spinal Cord— Compressio Medullae Spinalis. 

Etiology. Compression of the spinal cord may result from the 
pressure that is exercised by tumors, inflammatory exudations, or dis- 
eases of the spinal column and meninges, which invade the spinal canal 
and limit its capacity. 

Pathological Anatomy. Compression of the spinal cord produces a 
reduction in its magnitude at the point of pressure, and the constituent 
columns of the cord are flattened and atrophied to a degree that may 
occasion the complete disappearance of nervous elements. Secondary 
inflammatory changes are developed in the columns of the cord above 
and below the seat of compression ; and the course of these degenera- 
tive processes corresponds with the direction of the functional move- 
ments which they represent ; thus degeneration in the course of the 
pyramidal tracts is downward from the point of compression, while 
above the lesion it follows the opposite direction in the posterior columns 
and in the cerebellar tracts. The nerve roots and intervertebral ganglia 
become inflamed and atrophied, and the spinal meninges also become 
thickened and, sometimes, extensively inflamed. 

Symptoms and Diagnosis. The disease is ushered in by various 
disturbances of sensation, together with tenderness on pressure, and 
other evidences of local changes in the bones of the spinal column. 
After a time the symptoms of irritation are developed in the form of 
neuralgic pains and girdle-sensations, which are in many instances 
worse at night than during the daytime, and are aggravated by move- 
ment of the body. Various forms of hypercesthesia and paresthesia 
are manifested ; and trophic disturbances take the form of cutaneous 
eruptions, bedsores, or inflammation of the joints. Muscular spasms 
and contracture are frequently observed. Gradually, paralytic symp- 
toms become prominent. The muscles are flaccid, and locomotion be- 
comes impossible, though passive movements may still be resisted. 
Sometimes, when the cervical portion of the cord is involved, the arms 
alone are paralyzed, in consequence of compression involving the nerve 
roots rather than the spinal cord itself. In certain cases this is probably due 
to compression of the anterior cornua of the gray matter, or because 
the nerve paths to the upper extremities lie nearer to the periphery of 
the cord, and are more easily compressed, than those which descend to 
the lower extremities. The functions of the bladder and rectum are 
affected in a manner similar to what is observed in transverse myelitis. 

Cutaneous anaesthesia is gradually developed, although it seldom be- 
comes complete. Retardation of sensory impressions is sometimes 
observed. In certain cases the phenomena of anaesthesia dolorosa are 
manifested. This is a not uncommon incident in the course of cancer- 
ous diseases of the spinal column. 

When the anterior nerve roots are affected, the muscles with which 
they communicate undergo atrophy and exhibit the reaction of degene- 
ration ; while on the contrary, if the substance of the cord alone be 
subjected to pressure, reflex excitability is considerably increased, and 
the phenomena of ankle clonus are easily excited ; but, if the lumbar 
portion of the cord is subjected to serious pressure, these reactions dis- 



824 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

appear, in consequence of interruption of the reflex arc within the 
cord. 

Vasomotor disturbances are sometimes observed in the paralyzed 
limbs. 

Complete recovery may occur, even after severe paralysis, when the 
nerve elements of the cord have been in any way relieved from pres- 
sure before atrophy has destroyed their functional capacity. In many 
cases, though recovery never occurs, the symptoms present alternate 
improvement and aggravation ; but frequently the disease progresses 
steadily until it reaches a fatal termination. 

The development of secondary degeneration in the different columns 
of the cord is followed by the appearance of corresponding symptoms. 
Invasion of the lateral columns causes the previously flaccid muscles 
of the lower extremities to become rigid and contractured, so that the 
limbs are excessively flexed and adducted. The upper extremities 
sometimes become paralyzed at a late period, by reason of the upward 
extension of secondary degeneration to the cervical portion of the cord. 

Prognosis. The prognosis is usually unfavorable, though it is least 
so in cases that depend upon diseases which sometimes admit of recovery, 
as, for example, tuberculosis of the spinal column. 

Treatment. When compresion has been caused by injuries of the 
spinal column, it may sometimes be relieved by surgical operations for 
the reduction of dislocation, or for the removal of fractured portions of 
the vertebrae. In a few cases tumors have been successfully removed 
from the dura mater. In the majority of cases, however, the treatment 
of chronic myelitis is all that can be undertaken. 

Injuries of the Spinal Cord. 

Pathological Anatomy. Changes in the cord that are produced 
by injuries correspond to the nature of the traumatism and to the 
length of time which has elapsed since their infliction. Swelling, soft- 
ening, pigmentation, and fatty degeneration of the wounded tissues 
take place, and in cases of recovery cicatrization occurs. It is possible 
that sometimes a certain amount of regeneration of the nerve elements 
may be effected. Old injuries are frequently followed by secondary 
ascending and descending degeneration. 

Symptoms. The symptoms which appear after spinal injuries de- 
pend upon the situation and extent of the wound. As a general rule, 
motor and sensory paraplegia, with paralysis of the bladder and rectum, 
and alteration of the reflexes, are observed after transverse injuries of the 
cord. Vasomotor changes, such as pigmentation of the skin, abnormal 
temperature, and excessive perspiration, are frequently observed. When 
the injury involves the cervical or upper dorsal portion of the cord, 
priapism is not uncommon. Injuries involving the extreme upper por- 
tion of the cervical cord are speedily fatal. All the extremities are 
paralyzed, but the condition of the bladder and rectum depends upon 
the extent to which the lumbar portion of the cord has been involved 
by the shock of the injury or by secondary inflammation or degen- 
eration. In proportion to the distance of the seat of injury from the 



TRAUMATIC DISEASES OF THE SPINAL CORD. 825 

upper extremity of the cord will be the upper limit of sensory and 
motor symptoms in cases of spinal injury. When only one lateral half 
of the cord is wounded the symptoms of motor paralysis will be limited 
to the corresponding half of the body, producing spinal hemiplegia, if 
the lower extremity alone has suffered. 

Treatment. Injuries of the spinal cord generally fall within the 
limits of surgery. Their medical treatment consists in the administra- 
tion of mercurials and iodide of potassium ; and after the subsidence of 
acute symptoms, galvanic currents should be applied to the spine for the 
space of five minutes daily. 

Spinal Hemiplegia. 

Etiology. Spinal hemiplegia is dependent upon lesions that trans- 
versely involve one lateral half of the cord. They may be produced 
by fractures, dislocations, vertebral exostoses, hemorrhages, exudations, 
or tumors which impinge upon one side of the cord. The most char- 
acteristic examples are furnished by incised wounds of the cord, such as 
may be produced with knives, swords, or spears. 

Symptoms. Spinal hemiplegia is characterized by motor paralysis 
upon the side of the lesion, and sensory paralysis upon the opposite 
side of the body. If the injury be situated in the upper portion of the 
cervical cord, the arm and leg and muscles of the trunk upon the same 
side are paralyzed, while the opposite side of the body is insensible to 
all exterior impressions. Muscular sense alone is retained, since its 
fibres do not cross in the cord. Upon the injured side the sensory 
functions, with the exception of muscular sense, are all exalted. Cor- 
responding to the point of injury upon the paralyzed side is a narrow 
band of anaesthesia that occupies the lateral half of the body, and is 
anaesthetic by reason of the direct injury of the sensory nerve roots 
which enter the wounded portion of the cord. Immediately above the 
lesion is another band that surrounds the body, and is characterized by 
cutaneous hypercesthesia, probably occasioned by irritation of the pos- 
terior nerve roots upon both sides of the cord immediately above the 
seat of injury. 

Vasomotor disturbances are always observed in connection with 
hemisection of the cord. They are especially notable after injuries that 
involve its cervical portion and produce paralysis of the cervical sympa- 
thetic nerve. The cutaneous vessels are dilated and filled with blood, 
and the temperature of the skin is elevated two or three degrees above 
the normal level. The ear and side of the face are red and hot, the 
pupil is contracted, the conjunctiva is injected, tears flow more freely, 
the eyeball is retracted, and the palpebral fissure is narrowed. 

In severe cases trophic disturbances have been observed. The para- 
lyzed muscles undergo atrophy from disease, and their electrical ex- 
citability is diminished. The reflexes are usually exalted ; the bladder 
and rectum are frequently paralyzed. 



826 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

CHAPTER VI 

SYSTEMATIZED DISEASES OF THE SPINAL CORD. 

Progressive Locomotor Ataxia — Tabes Dorsalis. 

Etiology. The disease occurs far more frequently among men than 
among women, and in the majority of cases it originates during the 
most active period of middle life. About ninety per cent, of the cases 
are dependent upon previous syphilis, though it probably bears the 
same relation to that disease that so many other nervous diseases sus- 
tain toward infective diseases generally. It sometimes results from 
ergotism, and from poisoning with various species of lathyrus, or with 
carbon di- sulphide, lead and arsenic. It has been observed after ex- 
posure to severe cold, and as a consequence of violent exertion, wasting 
disases, venereal excesses, and injuries of the spinal column. The 
disease is sometimes developed in the course of progressive paresis. 
Tabes is usually encountered among people who are exposed to exces- 
sive labor under unfavorable conditions of weather and climate. It 
rarely occurs in tropical countries. 

Pathological Anatomy. In many cases the spinal disease is only 
apparent on microscopical examination, but often the posterior surface 
of the cord appears flattened and dwindled. The pia mater is often 
turbid and thickened. The substance of the posterior columns is gray, 
and its density is increased. The arachnoid and dura mater are fre- 
quently thickened and adherent to the subjacent surface of the cord. 
A cross-section reveals gray discoloration of the posterior column. 
which is most conspicuous in the lower dorsal portion of the cord, but 
can be frequently traced upward to the medulla oblongata, or even as 
high as the corpora quadrigemina. The posterior spinal nerve roots 
are dwindled and gray, but their atrophy never extends outward beyond 
the intervertebral ganglia Similar atrophic processes may be recog- 
nized in the cauda equina. 

The optic nerve undergoes degeneration from the eyeball backward 
as far as the corpora geniculata. Branches of the oculo-motor, trigemi- 
nal, glossopharyngeal, hypoglossal, and pneumogastric nerves undergo 
similar degenerative changes. Cerebral degeneration only occurs in 
cases that are associated with progressive paresis. 

The peripheral nerves are frequently attacked by inflammation which 
develops at their peripheral extremities, occasioning circumscribed 
cutaneous anesthesia, motor paralysis, joint diseases, visceral crises, 
and trophic changes in the nails and skin. A similar degeneration and 
atrophic conditions are observed in the muscular nerves. 

Microscopical examination reveals atrophy of the nerve elements. 
and increase of connective tissue in the degenerated portions of the 
posterior columns. Amyloid bodies are present in great number. The 
walls of the bloodvessels are thickened, the lymph spaces are loaded 



SYSTEMATIZED DISEASES OF THE SPINAL CORD. 827 

with minute oil globules and granular cells. The nerve fibres exhibit 
various degrees of atrophy and degeneration. The posterior cornua of 
the gray matter frequently appear shrunken, and their nervous elements 
(ganglion cells and fibres) are largely replaced by connective tissue. 
The vesicular columns of the cord exhibit atrophy of their nerve fibres, 
but the ganglion cells usually remain uninjured. 

The degenerative process frequently extends into the direct cerebellar 
tracts, and sometimes invades the lateral columns or even the anterior 
columns of the cord. Occasionally the large ganglionic cells of the 
anterior cornua become pigmented and atrophied, producing muscular 
atrophy during the life of the patient. 

In the lumbar region, the process of degeneration commences sym- 
metrically in the middle portion of the posterior columns of the cord ; 
respecting, however, a limited section immediately behind the posterior 
gray commissure and a small triangular space near the posterior ex- 
tremity of the gray cornua. In the dorsal division of the cord the 
degenerative process originates in the middle portion of the funiculus 
cuneatus, at the point where the fibres of the posterior nerve roots pass 
through its substance into the gray matter of the posterior cornua. The 
funiculi graciles are soon invaded, and finally the entire substance of 
the posterior column becomes involved. In the cervical division of the 
cord degeneration commences in the funiculi graciles, and gradually in- 
vades the remaining portion of the posterior columns. 

Symptoms. Tabes dorsalis is a lingering disease which gradually 
develops, and may persist for many years. It is not an uncommon 
event to meet patients who have suffered for more than a quarter of a 
century. Its course may be conveniently divided into three stages : 

First, a neuralgic or pre-ataxic stage, in which neuralgic pains, loss 
of the patellar reflex, oculo-motor paralysis, pupillary changes, optic 
nerve atrophy, anaesthetic and paresthetic disturbances, disorder of the 
functions of the bladder and rectum, and joint diseases are the most 
conspicuous symptoms. 

Second, an ataxic stage, in which the phenomena of ataxia are de- 
veloped in the lower extremities, and extend to the upper limbs. 

Third, a paralytic stage, in which locomotion is no longer possible, 
and muscular atrophy, paralysis of the bladder, decomposition of the 
urine, gastric crises, progressive exhaustion, bedsores, and other con- 
sequences of wasting disease render life utterly miserable. Death fre- 
quently results from tuberculosis or from intercurrent diseases. 

Pain is one of the earliest and most persistent symptoms. It fre- 
quently occupies the distribution of the sciatic nerve, and is mistaken 
for rheumatism or neuralgia. It occurs in paroxysms of burning, 
boring, or shooting pain which may continue for several hours at a 
time, or may assume the character of an electric shock (lightning pains). 
It is frequently aggravated at night and by cold weather, or other 
atmospheric changes. In many cases a sensation of constriction about 
the body is experienced, and severe gastraigia or pain in the bladder 
and rectum may be felt. Various forms of paresthesia, e. g., formica- 
tion, prickling, burning, sensations of cold, etc , frequently add to the 
sufferings of the patient. Ancesthetic spaces sometimes are discovered 



KM DISEASES J9 7HZ SPINAL :ORD AXI« MEMBBA2 

upon the surface of the skin, especially upon the thigh and perineum. 
At a later period the leg and foot are often involved, and perrerted 
sensation* are experienced in the act of walking, so that the patient 
feels as if his feet were placed upon feathers or upon fur. In many 
cases certain forms of sensibility disappear, while others are retained. 
S .rions may be retarded, so that perception occurs several seconds 
later than the cutaneous impression. Sometimes the prick of a pin is 
followed by double sensation, so that the first painful sensation see:, 
be followed after a few seconds by another still more painful impression. 
Sometimes a single contact, e. g., pressure with the head of a pin, is 
perceived as if a number of simultaneous impressions had occurred in 
neighboring portions of the surface (polyaesthesii . The muscular 
sense is abolished, and the tendons, muscles, and fascue become 
anaesthetic. 

As a consequence of the loss of muscular sense, it is impossible to 
stand erect with the eyes closed, or to move about in a darkened room, 
since the patient is unable to locate the position of his limbs, or t>: 
mate the amount of muscular contraction that is necessary to maintain 
or to change his position. 

The cutaneous reflexes exhibit little, if any. change, but the tendi- 
nous reflexes, especially the patellar reflex, disappear at a very early 
period in the course of the disease. This may be ascertained by sup- 
porting the thigh with the leg hanging freely from the knee, while the 
tendon below the patella is smartly tapped with a percussion-hammer, 
or with the border of the hand. In the majority of healthy p^: 
this operation is followed by an active contraction of the quadrice: 
tensor muscles of the thigh. When it is apparently absent, it n: 
frequently developed while the attention of the patient is distracted, by 
causing him to clasp the wrist with the other hand, and to make for- 
cible traction during the time of experiment. The patellar reflex is 
rarely present in tabes dorsal:-, excepting those cases in which the 
disease chiefly involves the dorsal portion of the cord while the lumbar 
portion remains undegenerated. leaving intact the reflex arc for the 
lower extremity (ataxic paraplegia). 

Vasomotor* secretory, and trophic disturbances are often a v 
during the whole course of the disease, but sometimes oedema and cold- 
ness :«f the extremities have been observed. In certain cases ezeen 
perspiration or ptyalism may occur at intervals, and sometimes cutane- 
ous eruptions, bedsores, pigmentation of the skin, thickening and fall- 
ing of the nails, and loosening of the teeth have been w The 
muscles may become wasted from disease, or. if the anterior cornua be- 
come degenerated, or peripheral neuritis be established, rapid atrophy 
and the reaction of degeneration become apparent. In certain cases 
the joints, especially the large joints of the extremities, become swelled 
without fever or pain. The cavity of the articulation is occupies 
serous fluid which, after several weeks or months, may disappear. 
Sometimes the ends of the bones undergo absorption, which de- 
the function of the affected joint. Frequently a certain degree of stiff- 
ness is experienced, with audible cracking of the joints during their 
flexion. These changes are referred to a concomitant arthritis defor- 



SYSTEMATIZED DISEASES OF THE SPINAL CORD. 829 

mans. In many cases the bones are extremely brittle, and their spon- 
taneous fracture may occur. The arch of the foot sometimes becomes 
flattened and distorted, and perforating ulcers are occasionally developed 
near the metatarso-phalangeal articulation of the great toe. 

Transient paralysis of the ocular muscles and of the muscles of the 
extremities are often observed. In the later stages of the disease the 
limbs become powerless from disuse. 

Subsequent to the. conclusion of the first stage of the disease, ataxia, 
or muscular incoordination, forms one of the most conspicuous symp- 
toms. The gait is uncertain, the foot is brought down upon its heel, 
the limbs are thrown out in a swinging or jerking manner, and it is 
impossible to follow a straight line along the floor. It becomes neces- 
sary, in consequence of the absence of muscular sense, to guide the 
footsteps by the aid of the eye, and that must be reinforced after a time 
by a cane, then by two canes, and finally it is impossible to walk with- 
out assistance. As the disease invades the upper portion of the cord, it 
becomes impossible to coordinate the muscles of the upper extremity 
for the performance of delicate movements, such as writing, threading 
a needle, or sewing. With his eyes shut, the patient can only with 
difficulty find the end of his nose with the tip of his finger. 

The functions of the bladder and rectum are frequently disordered, 
sometimes at an early period in the disease. In certain cases the symp- 
toms of spasmodic stricture make their appearance, or a continual 
dribbling of urine may annoy the patient. Complete paralysis and 
ulceration of the bladder sometimes exist, and may be followed by 
ammoniacal decomposition of the urine, with all its direful consequences. 

Paralysis of the ocular muscles has already been mentioned. The 
pupils are frequently contracted, or they may be of unequal diameter. 
Frequently they cease to respond to variations of light though their 
power of movement in the act of accommodation be preserved (Argyll- 
Robertson's pupil). In many cases the sense of sight is diminished or 
completely destroyed. The optic papilla is atrophied and gray. The 
lamina cribrosa is unusually distinct, and the retinal arteries are con- 
tracted. Gradually the field of vision becomes reduced, and color- 
blindness may be developed. 

Visceral crises are sometimes witnessed in connection with the inte- 
rior organs of the thorax or abdomen. They are characterized by dif- 
ficulty of swallowing, or by disturbances of respiration, convulsive 
cough, and asphyxia ; by irregularity in the movements of the heart, 
and by paroxysms of pain that resemble angina pectoris ; by severe at- 
tacks of vomiting and purging ; by paroxysms of pain which counterfeit 
the symptoms of renal colic, though blood and pus are absent from the 
urine. These crises have been ascribed to degeneration in the course 
of the peripheral nerves, or of their central nuclei. 

With the exception of the sense of vision the special senses are rarely 
affected. Auditory hallucinations and loss of hearing are occasionally 
experienced, and perversions of taste and smell have been noted. 

The intellectual functions are seldom disturbed, though despondency 
must necessarily be a common experience. Occasionally the disease 
becomes associated with symptoms of progressive paresis. Apoplecti- 



530 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

form or epileptiform seizures are sometimes experienced. The sexual 
appetite is often exaggerated at the commencement of the disease, but 
it finally undergoes complete subsidence. 

Diagnosis. Tabes dorsalis must not be confounded with conditions 
of profound neurasthenia in which the patellar reflex is absent. Cer- 
tain cases of diabetes mellitus also are accompanied by symptoms that 
closely resemble the symptoms of tabes : and alcoholic ataxia is some- 
times mistaken for the spinal disease, but it may be readily distinguished 
by reference to its cause, by the absence of ocular paralysis, by the 
presence of muscular tremor, and by the comparatively rapid recovery 
that follows judicious treatment. In many cases diffuse syphilitic 
disease in the spinal cord produces all the symptoms of tabes. 
bellar ataxia is to be differentiated by the persistence of the patellar 
reflex, by the widely staggering gait, and by the vomiting, vertigo, 
occipital headache, and choked disc which indicate cerebellar disease. 
Diphtheria and other infective diseases are sometimes followed by 
ataxic symptoms and by other phenomena which closely counterfeit dorsal 
tabes ; but in such cases pupillary symptoms are absent, the power of 
accommodation is lost for a time, and the history and course of the dis- 
ease enlighten the diagnosis. In certain cases, however, it must be 
admitted that peripheral neuritis is accompanied by an array of symp- 
toms that render it indistinguishable from the spinal disease. 

PROGNOSIS. The prognosis is extremely unfavorable. The disease 
is frequently incurable before it is recognized and subjected to treat- 
ment. Periods of improvement are not uncommon, especially during 
the warmer seasons of the year. Partial recovery is possible, but is 
liable to be followed by a relapse of the disease, sometimes after a 
number of years. 

Treatment. In all cases that have been preceeded by syphilis. 
the inunction of mercury and the administration of iodide of potassium 
should be conducted according to the method prescribed in the treat- 
ment of acute myelitis. In all cases the general treatment of myelitis 
should be recommended. If possible, the patient should be sent to a 
warm climate during the winter : and the pure air of a dry mountain 
retreat is advantageous during the summer. Ergot, belladonna, anil 
similar remedies should be avoided. Xitrate of silver may be given 
with advantage, in doses of one-fourth of a grain, three times a day. 
until two drachms have been administered : beyond that point there is 
danger of argyrosis. 

Ascending and descending galvanic currents along the spine are use- 
ful. Considerable relief from pain is derived from the faradic brush, 
and from the extensive use of dry cups upon the back. In certain cases 
of impending muscular paralysis, great benefit is sometimes obtained 
from the application of Junod's cupping apparatus to the extremities 
which the nutrition of the muscles is gradually improved. 

Stretching of the sciatic nerve was formerly practised for the relief 
of tabes, but is now quite out of date. Recently suspension, by the 
aid of Sayre's apparatus, has been practised for the same purpose. In 
many cases temporary or partial improvement has been observed, but 
sometimes no effect, or even an injurious influence, has followed this 



SYSTEMATIZED DISEASES OF THE SPINAL CORD. 831 

method of treatment. Suspension should be cautiously practised every 
other day, for half a minute at first, and its duration may be gradually 
increased to three minutes. This method should never be employed 
with patients of a feeble constitution, or with those who suffer from car- 
diac or pulmonary diseases. 

For the relief of pain, acetanilide or phenacetine may be administered 
in moderate doses for many months. The patient should be cautioned 
against the use of morphine and other opiates, otherwise he will inevi- 
tably fall a victim to the opium habit. 

Spastic Spinal Paralysis— Paralysis Spinalis Spastica. 

Etiology. Primary spastic spinal paralysis occurs more fre- 
quently among men than among women, and is usually observed be- 
tween the thirtieth and fiftieth years of life, though it is not uncommon 
among children. It may be produced by exposure to cold, by injuries 
and over-exertion, or as a consequence of difficulty in delivery at the 
time of birth. 

Secondary spastic spinal paralysis occurs as a complication of other 
spinal diseases. 

Pathological Anatomy. The spinal lesion is situated in the lateral 
columns of the cord, and consists of a degeneration involving the pyr- 
amidal tracts and their connections with the ganglionic cells in the 
anterior cornua of the gray matter. 

Symptoms, Diagnosis, and Prognosis. The symptoms in uncom- 
plicated cases take the form of weakness, rigidity, contracture, and 
paralysis of the muscles, associated with exaltation of the tendinous 
reflexes, while the functions of sensation and of the bladder and rectum 
remain unchanged. The cerebral nerves also remain intact. 

The disease usually invades the lower extremities, and gradually 
progresses upward. Occasionally it follows the opposite course, or may 
be restricted to a single extremity, or to one side of the body. 

The earliest symptom consists of weakness and stiffness of the mus- 
cles. Sometimes spasmodic movements are witnessed. The extensors 
and adductors of the thigh gradually become contractured. The flexor 
muscles of the foot draw the extremity into the position of pes varo- 
equinus. It becomes difficult to raise the foot from the floor ; the toes 
drag and strike the heel of the forward foot, so that it seems as if the 
patient would fall forward by reason of the entanglement of his lower 
limbs. Occasionally the body is jerked upward, and the foot is raised 
upon its toes at every step (saltatory spasm). In the later stages 
of the disease, locomotion becomes utterly impossible and the lower 
limbs remain excessively flexed and adducted. Similar conditions are 
manifested in the upper extremities and by the muscles of the body in 
the back. 

The electrical excitability of the muscles exhibits no considerable 
change. In many cases cutaneous sensibility undergoes paresthetic 
perversions, but vasomotor and trophic changes are not developed. 

The cutaneous reflexes exhibit little alteration, but the tendinous 
reflexes are greatly exaggerated. A tap upon the tendons or upon 



832 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

the bones in any portion of the extremities is followed by excessive 
clonic muscular contraction. Ankle-clonus may be excited to an inor- 
dinate degree, but can be promptly inhibited by forcible plantar flexion 
of the great toe. 

The disease may be protracted for an exceedingly variable period of 
time. In certain cases it runs its course in a few weeks, while in others 
it has been known to persist for more than thirty years ; death occurs 
as a result of intercurrent diseases. 

Treatment. The galvanic current should be applied to the spine, 
after the manner recommended for the treatment of tabes dorsalis. 
Warm baths of every description are useful, and iodide of potassium 
may be given internally. Suspension has been tried with some degree 
of success. Tenotomy and orthopsedic treatment are necessary for the 
relief of deformities. 

Acute Infantile Paralysis— Poliomyelitis Acuta Anterior Infantilis. 

Etiology. Infantile paralysis is a very common disease of child- 
hood. It is generally observed during the eruption of the first set of 
teeth, and it rarely occurs after the commencement of second dentition. 
Nearly twice as many male as female children are attacked by the dis- 
ease. It frequently follows the occurrence of infective diseases, and is 
often encountered among the children of neurotic families. Its sudden 
invasion and often tumultuous course are highly suggestive of an infec- 
tive origin, which opinion is additionally reinforced by its occasional 
epidemic prevalence in certain localities. It is also a disease of the 
summer months, during which infective causes of a certain character 
are most prevalent. 

Pathological Anatomy. It occasionally happens that the symp- 
toms of acute poliomyelitis exist as a result of inflammatory processes 
which were primarily developed in the membranes and white substance 
of the cord, and had extended into the gray matter of the anterior 
cornua ; but in the vast majority of cases the disease has its primary 
seat in the gray matter, where it exists as an acute inflammation of the 
ganglionic cells in the anterior cornua. Microscopical examination 
reveals such inflammatory processes, principally in the lumbar and cer- 
vical enlargements of the cord. The number and extent of these points 
of inflammation is variable, and they may occupy one or both sides of 
the cord. The bloodvessels are dilated and distended with blood, their 
walls are thickened by the proliferation of their nuclei, and the usual 
appearances of inflammatory exudation are present in their immediate 
vicinity. The neuroglia undergoes proliferation, the ganglionic cells 
are vacuolated and otherwise distorted or destroyed. The nerve fibres 
to which they give origin become atrophied and disappear. In ad- 
vanced cases the entire cornu becomes atrophied and shrunken by 
sclerotic and pigmentary degeneration. Similar processes of degenera- 
tion are sometimes discovered in the vesicular columns, and in the 
anterolateral tracts of the cord, and in the anterior nerve roots ; but 
the posterior nerve roots and the posterior cornua remain without 
change. 



SYSTEMATIZED DISEASES OF THE SPINAL CORD. 833 

Those peripheral nerves that are in immediate connection with the 
diseased portions of the cord, and the muscles with which they com- 
municate, undergo degeneration. The muscular tissue becomes pale, 
the fibres dwindle and break up into their constituent fibrils, their 
striation disappears, and the connective tissue is increased. Among 
the atrophied fibrils are visible others which appear hypertrophied, but 
this is probably only another form of degeneration. Not unfrequently 
the connective tissue becomes loaded with fat to an extent that masks 
the dwindling of the muscular substance ; but when this event does not 
occur, the degenerated muscle presents the appearance of a thin, pale 
band of connective tissue. The inter -muscular nerves also undergo 
similar changes. 

The process of atrophy and retarded development is not confined to 
the muscles alone, but involves the bones and other tissues of the 
affected limb, so that it remains permanently smaller than its healthy 
companion. Sometimes the superficial layers of fat are sufficiently 
developed to conceal, in some measure, the retarded growth of the 
limb. 

Symptoms. The symptoms of acute infantile paralysis are devel- 
oped in the form of a sudden and complete flaccid paralysis, involving 
certain muscles which become rapidly atrophied, and exhibit the reac- 
tion of degeneration, together with loss of cutaneous and tendinous 
reflexes, and the absence of trophic changes in the skin, while the 
power of sensation and the functions of the bladder and rectum remain 
unaffected. The disease frequently commences in the night, with a 
high fever, often accompanied by epileptiform convulsions and other 
evidences of cerebral disturbance. On lifting the child from his bed, it 
is discovered that one or more of the limbs are in a condition of flaccid 
paralysis. In the course of three or four days the fever and other 
acute symptoms disappear. Sometimes paralysis is suddenly and com- 
pletely developed without any accompanying febrile movement, and 
the condition is accidentally discovered before anything unusual attracts 
attention to the health of the patient. Usually, however, pain that is 
aggravated by movement attracts the notice of the mother, and the 
other symptoms are rapidly developed to an alarming extent. 

Paralytic symptoms usually involve the lower extremities, but their 
distribution is sometimes quite irregular. The muscles of the trunk 
sometimes participate in the paralysis, and in rare instances the facial 
muscles also are involved. At first all the muscles in an extremity ap- 
pear to be motionless, but in the course of a few days or weeks the 
power of voluntary movement is partially restored, and certain muscles 
recover their former vigor, while other groups remain permanently 
paralyzed and undergo atrophy. The disease exhibits a marked ten- 
dency to invade groups of muscles, since the ganglionic cells in the 
anterior cornua are connected with muscular groups, rather than with 
single muscles. Thus, in the upper extremity, the deltoid, biceps, 
brachialis internus, and the supinator muscles form a group which fre- 
quently undergo simultaneous paralysis, while the extensor muscles of 
the forearm form another group that may be similarly affected. In 
the lower extremity the sartorius muscle generally escapes in cases of 

53 



:\- : : f :zi ?; ,. com axb isibba: : 



< -Lire- .:. "-r ; .:-.."- c :: "_- 



the dcrofepaieat of the rxmdtkm #/ ih^ntfiM, allff tke buis fkat 




fcasL As the child grows ap* the 

•fellows in the mam&er rf *jwsnL *hh1 l*e$**rm#bti fecjaeadr 
:_t . lit .- :. : --=.:!-= L± i - rf~Li*: "_. ".-_'- 
prhcd of their aatagoaisBs. Ie the fewer exireaut 

"---. - ^:t :i-= /- -.] ri _'_.t il-- ill- i-tl.: - •: 
Yajriaas fe«^ m *f**tal ewrvafrwi are pr&daced. amd the 
max amdergo partial laxatioa from atropk y of the deltoid aausele. Tfee 
dbow-joiat is TMiihr aifecaed. bat deformities of tike Band are aot aa- 

does aot appear to be shortened kAe disease, thoa^a ia certaia ia- 

A-sate aaterior ooiioarrelitis sansr lie drtHaaai saed 



1. Prs^pnmme wmmrnktr mSw^pkg^ a disease 
dtf Mica i aad m wry alaaly d^tilupuiL 

. P&aufe-ajgMrfrti^^ 
dee do ant dwiadle, aad which is very dowty developed. 

o. Spag&t *pms2 pmrwfyms esldfes great exa^nerataaa off the am- 

• ,— i -»-_ — - -T- -; . • - _ 

-L BirtJtt-paflMiv origiaalrff ait the ttawe of defirovy. asataBy as a eoase- 




ft. 

Pe<&5S-.qsk- The prognosis is aairoorabl 
paralyzed awsdes is concerned. After tke fast tew days the 1 
the paint is rarely ia daager. FaiaHtie 
aay iaipninaiial after the eapaaiioa of »ix< 

Z:i^zxi:. r z ^.::::::.:.:./:":' nn m-tis lz.5 
aaav be colored. As febrile srmpoms sabside, am iee h^ 
wkbawdia to prolix tke aa^AoaUWImidasaiast the back. Iodide J 
ofpotassiaaiany be adauaistered ia aWs tkat correspoad to the age 
of the child. BeBadoaaa aad ergot are reeoaaawaded by soaae pfoys- 
ciairt Alter the expiratioa of a week, the galiaaie carreat aaay be 
applied to the spiae with the aid of huge 



SYSTEMATIZED DISEASES OF THE SPINAL CORD. 835 

A daily warm bath, in which salt has been dissolved, is of considerable 
service, and the paralyzed limbs should be thoroughly rubbed and 
gently kneaded every morning and evening. When the muscles react 
under the faradic current they should be moderately exercised by its 
aid. Electrical treatment should be discontinued at the end of six 
weeks, that the patient may rest for a week or two before it is again 
resumed. In this way, successive periods of treatment and rest should 
follow one another so long as improvement continues. Old cases in 
which the limbs have become deformed by contractures require ortho- 
paedic treatment. 

Acute, Subacute, and Chronic Spinal Paralysis of Adults— Polio- 
myelitis Acuta, Subacuta et Chronica Anterior Adultorum. 

An acute form of anterior poliomyelitis which in no respect differs 
from the infantile form of the disease is sometimes encountered among 
young adults. Its causes, course, and results apparently differ in no 
essential particular from those which characterize the infantile disease. 

A subacute and chronic form is sometimes observed after middle life. 
It is occasionally produced by lead poisoning. It generally commences 
gradually, without any serious disturbance of the general health. It 
usually invades the lower extremities, and slowly advances upward, 
attacking one group of muscles after another, and sometimes finally in- 
vading the bulbar nerves and their dependent muscles. 

The paralyzed muscles are flaccid and undergo acute atrophy, ex- 
hibiting the reaction of degeneration and other symptoms that accom- 
pany the course of infantile poliomyelitis. During convalescence the 
course of improvement in the condition of the muscles is the reverse of 
the order of their invasion. The disease in fatal cases continues from 
one to four years. After death the ganglionic cells in the anterior 
cornua of the cord are found to be atrophied and destroyed. 

From progressive spinal atrophy the disease may be differentiated 
by the occurrence of paralysis involving entire muscles before their 
atrophy takes place. 

From amyotrophic paralysis it may be differentiated by the absence 
of muscular rigidity, spasm, and exaggerated tendinous reflexes. 

Multiple degenerative neuritis, with which this disease might be 
confounded, differs by the presence of sensory disturbances. 

Spinal Progressive Muscular Atrophy— Atrophia Musculorum 
Progressiva Spinalis. 

Etiology. Spinal progressive muscular atrophy is dependent upon 
a disseminated chronic anterior poliomyelitis. It usually commences 
in the upper extremities, gradually invading the muscular fasciculi one 
after another, and producing a progressive paralysis as the result of 
atrophy, without disturbance of the bladder or rectum or cutaneous 
sensibility. The disease is usually encountered during middle life, and 
is more frequently observed among men than among women, probably 
by reason of their greater exposure to cold and to the injurious effects 
of excessive exertion. 



836 DISEASES OF THE SPIXAL CORD AND MEMBRANES. 

Symptoms. Progressive wasting and weakening of the muscles 
mark the course of the disease. The interosseous muscles and the ?nus- 
cles of the thenar and hypothenar prominences are first invaded. The 
furrows between the metacarpal bones become strongly pronounced, and 
the fleshy portions of the hand exhibit a shrunken appearance. The fin- 
gers become incapable of delicate movements, and. by reason of the loss 
of power in the adductor and opponens pollicis muscles, the thumb 
can no longer be brought into accurate opposition to the fingers : it is 
also drawn backward by the extensor and abductor muscles, so that the 
hand assumes an ape-like form. At the same time the second and 
third phalanges of the fingers can no longer be extended, through the 
failure of the interosseous muscles. The proximal phalanges are drawn 
backward by the extensor muscles, and the fingers assume the form and 
position of claws. 

Sometimes the atrophic process overleaps the muscles of the arm and 
invades the deltoid muscle, during the second stage of the disease. 
The posterior and the middle portions of the muscle are first invaded, 
and the process of atrophy extends from one bundle to another until 
the shoulder is completely flattened, and only the skin seems to cover 
the bones. Partial luxation of the joint takes place, and the arm hangs 
like a dead weight by the side. 

When the forearm is invaded, the extensor muscles usually suffer 
first. The supinator muscles and the flexor muscles of the forearm fail 
together. The disease exhibits a tendency to invade muscles that are 
associated in functional groups, but finally the entire extremity is in- 
volved. In the majority of cases the disease commences upon the 
right side, and exhibits a tendency to attack the corresponding muscles 
upon the other side, as *a consequence of the extension of the disease 
from one side of the cord to the corresponding group of cells upon the 
other side, before it extends in a vertical direction. After the upper 
extremities have been thoroughly occupied by the disease the muscles of 
the shoulders, back. l>ody. and neck are also drawn into the course of 
degeneration. When the lumbar muscles give way, the patient leans 
backward so far that a line dropped from the shoulders falls behind the 
sacrum : but if the abdominal muscles are weakened, though the loins 
are thrown forward, a perpendicular line from the shoulders passes 
through the sacrum. The lower extremities generally exhibit atrophy 
in the extensor muscles of the thigh. It is less commonly observed in 
the hip and in the calf of the leg. 

As the atrophic process works its way among the muscular fasciculi, 
fibrillary contractions become visible beneath the overlying skin. Their 
cause is not fully understood, but it is undoubtedly connected with the 
process of atrophy. 

The electrical reactions correspond to the condition of the affected 
muscles. As the muscular tissue wastes it ceases to respond to electri- 
cal excitation. The reaction of degeneration is correspondingly dis- 
played, first as a partial, and finally as a completely developed phe- 
nomenon. In like manner, the cutaneous and tendinous reflexes grad- 
ually disappear; but the power of sensation and the functions of the 



SYSTEMATIZED DISEASES OF THE SPINAL CORD. 837 

bladder and rectum remain unchanged ; the pupils vary in diameter, 
react sluggishly to light, and gradually lose the power of dilatation. 

Vasomotor and trophic changes are frequently observed in the skin. 
The temperature of the surface is considerably reduced. Sometimes 
copious perspiration occurs; and fas joints may become enlarged. 

The general health suffers comparatively little, though the long 
course of the disease produces the usual consequences of protracted 
confinement. 

In certain cases the nuclei of the bulbar nerves are invaded, and the 
atrophic process is manifested in the muscles of the face, tongue, 
pharynx, and larynx, producing the symptoms of a gradually progres- 
sive bulbar paralysis. 

Death usually results from intercurrent diseases, or from gradual 
exhaustion, or from the consequences of bulbar paralysis, if that be 
developed. 

Pathological Anatomy. Progressive muscular atrophy is the 
direct result of a chronic primary inflammatory atrophy of the ganglionic 
cells in the anterior cornua of the spinal cord. In many cases the 
anterior nerve roots and the peripheral nerves also undergo regenera- 
tion. In the muscles the intermuscular connective tissue and the sarco- 
lemma undergo a proliferation of their elements. The muscular 
substance becomes granular or waxy, and breaks up into fibrils or 
transverse segments, and gradually disappears. The degenerated 
muscles are either pale, or darkened by the deposit of pigment in their 
substance. Fatty degeneration rarely occurs, but the muscular mass 
undergoes a species of fibrous degeneration, analogous to that of hepatic 
cirrhosis. 

Diagnosis. Muscular atrophy must be distinguished from : 

1. Myopathic muscular atrophy, a disease which is usually heredi- 
tary, and is encountered among young people. It usually attacks the 
lower extremities or the face, and is more gradually developed. Fibril- 
lary contractions and the reaction of degeneration are generally absent. 

2. Multiple degenerative neuritis is characterized by the development 
of paralysis before the occurrence of atrophy. The muscles and nerves 
are sensitive to pressure, and painful disturbances of sensation are 
present. 

3. In the different forms of poliomyelitis, paralysis also precedes the 
development of atrophy and the reaction of degeneration. Sensory dis- 
turbances are absent, and the functions of the bladder and rectum are 
preserved. 

4. Syringomyelia and hydromyelia are accompanied by anaesthesia 
and disturbance of the sense of temperature. 

5. Muscular atrophy that is dependent upon articular diseases is 
preceded by the joint disease, and is clearly connected with it. 

6. The secondary muscular atrophy which follows various diseases 
of the spinal cord can be easily distinguished by its characteristic asso- 
ciation with the other symptoms of the spinal disorder. 

Prognosis. The prospect of recovery from spinal progressive mus- 
cular atrophy is very unfavorable, though the disease may persist for 
many years before a fatal termination is reached. 



333 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

Treatment. The general treatment of chronic myelitis is appro- 
priate in cases of progressive muscular atrophy. Electricity should be 
employed in the form of the galvanic current, conducted by the aid of 
large electrodes in alternately opposite directions. Moderate faradic 
currents may also be applied to the affected muscles. 



CHAPTER Til. 

COMBINED SYSTEM-DISEASES OF THE SPINAL CORD. 

Hereditary Ataxia— Ataxia Hereditaria. 

Hereditary ataxia occurs in certain families, attacking the female 
members more frequently than the male. It is usually developed in 
childhood, and is characterized by ataxic movements which speedily 
involve all the extremities and the muscles of the eyes, as well as those 
which are concerned in the act of articulation. Paralysis of the ocular 
muscles, pupillary symptoms, and amaurosis do not occur, nor are the 
bladder and rectum involved. Sensory disturbances, visceral crises, 
and the characteristic pains of tabes dorsalis are also absent. The 
patellar reflex disappears, but the patient experiences less difficulty in 
balancing himself with the eyes shut than is observed in tabetic cases. 
Vasomotor and secretory disturbances are commonly observed : and some- 
times epileptic convulsions or mental derangement may occur. Mus- 
cular paralysis, contractures, and deformities develop in the course of 
time. After death the posterior columns of the cord and the antero- 
lateral columns, to a certain extent, are found in a condition of degen- 
eration. The posterior columns of the cord are principally involved, 
while the anterior columns are but slightly invaded. The disease con- 
tinues for a lifetime, and is not amenable to treatment. 

Secondary Degeneration of the Spinal Cord. 

Allusion has already been made, in connection with the subject of 
compression of the spinal cord, to the fact that secondary degeneration 
may invade the spinal tracts, in an ascending or descending direction 
which corresponds with the physiological functions of those paths. 
Diseases that involve the trophic centres of the different columnar tracts 
in the spinal cord are followed by similar degeneration in those tracts. 
Thus the central convolutions of the brain contain the trophic cells which 
maintain the integrity of the descending pyramidal tracts. Lesions of 
the central convolutions are, therefore, followed by the rapid develop- 
ment of descending degeneration, which may be traced, through the 
corona radiata and the anterior two-thirds of the posterior limb of the 
internal capsule, into the inferior portion of the cerebral peduncle and 
beneath the pons Varolii, as far as the decussation of the pyramids, 
where the path of degeneration is divided and passes downward in the 



COMBINED SYSTEM-DISEASES OF SPINAL CORD 839 

corresponding crossed and direct pyramidal tracts, as far as their ter- 
mination at the level of the third and fourth sacral nerve roots. The 
degenerated tracts may be recognized above the cord by the gray and 
sunken appearance of their dwindled fibres, which lie immediately 
underneath the surface of the pia mater. Within the cord it is neces- 
sary to resort to microscopical examination, in order to follow the course 
of degeneration. 

The affected portion consists of nerve fibres which have undergone 
the ordinary changes of degenerative atrophy. The symptoms of the 
disease take the form of muscular contractures and exaggeration of 
the tendinous reflexes upon the side that corresponds to the anterior 
cornu which communicates with the degenerated pyramidal tract. 

Ascending degeneration in the spinal cord involves the cerebellar 
tracts when their trophic centres in the vesicular columns are destroyed. 
The course of degeneration may then be traced from the level of the 
mid-dorsal portion of the cord, where that column originates, upward 
to the cerebellum. The funiculi graciles are connected with trophic 
cells in the ganglia upon the posterior spinal nerve roots, and when those 
centres are diseased or destroyed, ascending degeneration follows the 
path of the funiculi to the corpora restiformia. Degeneration of these 
ascending paths produce no symptoms that admit of recognition. 

Amyotrophic Lateral Sclerosis — Sclerosis Lateralis Amyotrophia. 

Amyotrophic lateral sclerosis consists of a combination of primary 
degeneration in the pyramidal tracts of the spinal cord and of the 
ganglionic cells in the anterior cornua, together with the nuclei of the 
hypoglossal, spinal accessory, pneumogastric, and facial nerves. The 
disease usually occurs during the most active period of middle life, and 
is more frequent among women than among men. 

Pathological Anatomy. The disease commences in the lateral 
columns of the cord, and is most extensively developed in its cervical 
portion. It sometimes extends upward into the cerebral peduncles and 
corona radiata of the brain, involving the large ganglionic cells in the 
cortical portion of the central convolutions. From the lateral columns 
of the cord it extends into the anterior cornua, where it occasions 
proliferation of the neuroglia, with atrophy and disappearance of the 
ganglionic cells. In certain cases the disease commences in the gray 
matter and thence extends outward into the white columns. 

Sometimes the posterior columns of the cord participate slightly in 
the morbid process. The anterior nerve roots, the peripheral nerves, 
and the muscles with which they are in communication, in like manner 
undergo atrophic degeneration. Occasionally the atrophied muscles are 
so loaded w T ith fat that their volume appears undiminished. 

Symptoms. Amyotrophic lateral sclerosis presents the symptoms of 
spastic spinal paralysis, together with those of spinal progressive mus- 
cular atrophy and bulbar paralysis. Sensory disturbances and func- 
tional disorders of the bladder and rectum are absent. Muscular 
paralysis, rigidity, spasm, and contracture are developed in the upper 
extremities and progress downward to the lower extremities. The 



840 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

muscles in the arm become rapidly atrophied. When the disease pro- 
gresses upward the muscles that are in communication with the bulbar 
nerves also fall into a condition of atrophy. 

The disease is frequently ushered in by various par aesthetic sensa- 
tions in the arms. Gradually the stiffened limbs become weaker, and 
are drawn against the side of the body. The forearm is semiflexed and 
pronated. The hand is strongly flexed and the fingers are drawn into 
the palm. This result of the sclerotic process in the lateral column of 
the cord is soon followed by atrophy of the muscles, which is dependent 
upon the extension of the disease into the gray matter. Fibrillary con- 
tractions accompany this process ; the muscles are sensitive to pressure 
and exhibit the reaction of partial degeneration. Similar changes are 
exhibited by the muscles of the body and of the lower limbs, as the 
disease progresses, though the muscles of the inferior extremities ex- 
hibit only that form of wasting that is dependent upon disuse. They 
become contractured, and the tendinous reflexes are exaggerated, as in 
spastic spinal paralysis. 

Diagnosis and Prognosis. Amyotrophic lateral sclerosis must be 
differentiated from progressive muscular atrophy, in which paralysis 
follows atrophy and is developed fascicle by fascicle, instead of invad- 
ing whole muscles at once. In progressive muscular atrophy, however, 
muscular rigidity is absent. Atrophy commences in the muscles of the 
hand, and the atrophied muscles are painless on pressure. The tendi- 
nous reflexes disappear, and the course of the disease is much longer than 
that of lateral sclerosis. 

Hypertrophic cervical pachymeningitis differs by the predominance 
of the symptoms of irritation at the commencement of the disease, by 
the great disturbance of sensation which it occasions, by its limitation 
to the cord, and by the possibility of recovery in certain cases. 

Treatment. The disease should be treated like spastic spinal 
paralysis. • 



CHAPTEK VIII. 

DISEASES OF THE MEDULLA OBLONGATA. 

Progressive Bulbar Paralysis — Paralysis Glosso-labio-laryngea. 

Etiology. Progressive bulbar paralysis is caused by atrophy of 
the ganglionic cells in the nuclei of the nerves which spring from the 
floor of the fourth ventricle. The dependent muscles undergo atrophy 
and progressive paralysis, in consequence. 

The disease may be either primary or secondary , according to its in- 
dependent origin in the medulla oblongata, or its secondary extension 
from the ganglionic clusters in the anterior cornua of the spinal cord. 
It occurs most frequently among men after the middle period of life, 



DISEASES OF THE MEDULLA OBLONGATA. 841 

and may be excited by any of the causes that produce spinal progres- 
sive muscular atrophy. 

Symptoms. As a rule, progressive bulbar paralysis is gradually 
developed with various disturbances of sensation in the neck and oc- 
cipital region. After a time the movements of the tongue become 
impaired, articulation and the act of mastication are rendered increas- 
ingly difficult. The lips and orbicularis oris muscle become atrophied 
and paralyzed. Finally, the muscles of the fauces, pharynx, and 
larynx become similarly aifected. The tongue lies upon the floor of 
the mouth, and appears wrinkled and shrunken. Fibrillary contrac- 
tions are often visible in its substance. The articulation of sounds 
which depend upon movements of the tongue is progressively impaired. 
It becomes impossible to pronounce E, B, C, S, L, K, Gr, T, D, and 
N. The management of food and its propulsion into the pharynx is 
rendered difficult, and finally impossible. As the orbicularis oris mus- 
cle is invaded by atrophy and paralysis it becomes difficult to utter the 
sounds indicated by the letters 0, U, E, A, P, F, K, M, and W. The 
mouth remains permanently open, and as a consequence of the exag- 
geration of the salivary secretion, there is a constant overflow of saliva 
from the corners of the mouth and over the lower lip, producing excoria- 
tion of the chin. The muscles that are connected with the inferior 
branches of the facial nerve become paralyzed, but the frontal branch 
escapes injury, so that the wrinkled appearance of the forehead con- 
trasts strongly with the passive immobility of the face and the stupid 
gaping of the mouth. As the faucial, pharyngeal, and laryngeal 
muscles become invaded, speech grows nasal, and it is no longer pos- 
sible to pronounce the letters B and P. The act of deglutition becomes 
difficult and attended with danger, since food and liquids are liable 
either to regurgitation into the naso-pharyngeal passage, or to find 
their way into the larynx, producing symptoms of suffocation, or giving 
occasion for the development of catarrhal pneumonia. 

In certain cases the degenerative process invades the external rectus 
muscle of the eyeball, the masticatory muscles, and the muscles of the 
neck and head. When the disease progresses downward from the 
bulbar region into the spinal cord the ordinary symptoms of spinal 
progressive muscular atrophy are developed. The brain is never in- 
volved, and conscious intelligence remains unchanged through the w r hole 
course of the disease. The mechanical irritability of the diseased mus- 
cles is somewhat increased, and the reaction of partial degeneration 
is exhibited by the nerves and muscles under the influence of the gal- 
vanic current. Cutaneous sensibility remains without change. The 
course of the disease varies from one to three years, or more, and death 
results from the various consequences of paralysis of the different bulbar 
nerves, unless some accidental and intercurrent disease should previously 
terminate life. 

Pathological Anatomy. The disease is restricted to the nuclei of 
the bulbar nerves. The sympathetic ganglia and nerves remain un- 
changed. The large ganglionic nerve cells in the anterior cornua be- 
come distended with yellow granular pigment, their nuclei and proto- 
plasmic processes disappear, and finally the cells themselves break 



842 DISEASES OF THE SPINAL CORD AND MEMBRANES. 

Fig. 15S. 



=Dl^ 




Diagram to illustrate the position of the nuclei ot the cranial nerves indicated by Roman 
numerals. (Sherrington.) 



DISEASES OF THE MEDULLA OBLONGATA. 843 

down and are absorbed. The process consists of a primary degenera- 
tive atrophy, similar to what takes place in the anterior cornua during 
the course of spinal progressive muscular atrophy. The fibres in the 
bulbar nerves also undergo similar degenerative atrophy. The accom- 
panying diagram readily explains the progressive invasion of the bulbar 
nuclei, and the grouping of the consecutive symptoms. (Fig. 158.) In 
the muscular tissue of the atrophied muscles, wasting and disappearance 
of the contractile tissue and proliferation of the interstitial connective 
tissue may be readily discovered. The progressive invasion of the 
muscle, fibre by fibre, is also apparent, as it is in spinal cases ; and 
sometimes the accumulation of fat in the connective tissue is sufficient 
to conceal the evidences of reduction in the volume of the muscular 
fibres. In certain cases the evidences of muscular degeneration are 
only apparent under the microscope, so that this method of investigation 
should never be omitted. 

Diagnosis. 1. The differential diagnosis of bulbar paralysis requires 
attention to the fact that the symptoms of bulbar paralysis may be de- 
veloped without any accompanying changes in the central nervous 
system (pseudo-bulbar paralysis). This disorder is usually attended 
with symptoms of fever. 

2. Hemorrhages, thrombosis, and embolism oj the medulla oblongata 
may occasion symptoms of bulbar paralysis ; but they are developed 
suddenly, and are associated with sensory disturbances and other evi- 
dences of paralysis, unaccompanied by wasting of the muscles and 
change in the electrical reactions. 

3. Compression of the medulla oblongata and the bulbar nerves by 
tumors and aneurisms sometimes produces paralytic symptoms which 
also involve the auditory and trigeminal nerves ; but the other symptoms 
of pressure are also exhibited in the form of convulsions, vomiting, 
vertigo, choked-disc, and loss of vision. 

4. Hemorrhage involving both hemispheres of the cerebellum might be 
followed by bulbar symptoms ; but in such cases the muscles do not 
become atrophied, since their trophic centres remain unharmed, and the 
electrical reactions are unchanged. Respiratory and laryngeal dis- 
orders are also absent. 

5. Multiple cerebrospinal sclerosis has been observed with associated 
symptoms of bulbar paralysis ; but in such cases other symptoms of 
cerebral and spinal disease are apparent. 

6. Congenital bulbar paralysis, which has been observed among 
young children, recovers either spontaneously, or under the influence of 
electrical treatment. 

Prognosis. The prognosis in cases of well-marked progressive bul- 
bar paralysis is quite hopeless, though improvement is sometimes 
observed in cases of syphilitic origin. 

Treatment. In many cases it becomes necessary to make use of 
liquid food, and to resort to the use of the oesophageal sound for its 
administration. Excessive salivation may be relieved by the use of 
atropine. At the commencement of the disease counter- irritation 
should be applied to the back of the neck, and the bowels should be 
gently opened. Iodide of potassium should be administered internally, 



841 DISEASES OF THE SPINAL CORD AXD MEMBRANES. 

and in syphilitic cases the inunction of mercurial ointment must be 
practised. Salt-water baths are beneficial, but cold baths should be 
avoided. Very little benefit can be expected from ordinary nervine 
remedies ; but the galvanic and faradic currents may be employed with 
benefit. In the last stages of the disease the symptoms of asphyxia 
may render it necessary to perform tracheotomy. 

Progressive Nuclear Ophthalmoplegia— Ophthalmoplegia Progressiva 

Nuclearis. 

This disease consists of a paralysis of the external ocular muscles. 
In typical cases the muscles of accommodation and of pupillary reaction 
to light remain unchanged. In certain cases the disorder is associated 
with progressive bulbar paralysis, with progressive muscular atrophy, 
or with tabes dorsalis. The duration of the disease is exceedingly 
variable, and in acute cases may result in recovery. The symptoms 
are the consequence of degenerative atrophy of the nuclear cells in which 
the oculo-motor, trochlear, and adducent nerves originate, along the 
floor of the third ventricle and aqueduct of Sylvius. Under such cir- 
cumstances the disease is developed gradually, but when the paralytic 
symptoms result from thrombosis, or embolism, or hemorrhage, obstruct- 
ing the circulation of blood in the nuclei, the symptoms are developed 
suddenly. A functional form of ophthalmoplegia is sometimes observed 
which corresponds to the analogous functional variety of bulbar paral- 
ysis. 

Progressive ophthalmoplegia is sometimes congenital, but it may be 
the consequence of injuries, syphilis, or other infective diseases, lead 
poisoning, chronic alcoholism, and diabetes. Treatment with iodide 
of potassium affords the best results, and is sometimes followed by re- 
covery. 

Bulbar Hemorrhage— Hsemorrhagia Medullse Oblongata^ 

Hemorrhages that are limited to the medulla oblongata are exceed- 
ingly rare. They produce changes similar to those which are observed 
in cases of analogous hemorrhage into the spinal cord ; and they are the 
result of the rupture of miliary aneurisms in the arterial vessels. Death 
speedily results in the majority of cases, preceded by the symptoms of 
severe apoplectic or epileptiform seizure. The pulse becomes irregular 
and inordinately frequent, and the temperature is excessively elevated. 
Paralytic symptoms may involve one or all four of the extremities, and 
may be direct or crossed, according to the position and extent of the 
hemorrhage. Symptoms of irritation of the cerebral nerves at a dis- 
tance from the seat of hemorrhage may be associated with symptoms of 
bulbar paralysis extending also to the extremities. A fatal result is 
almost inevitable, and the treatment is that which will be described in 
connection with the subject of cerebral hemorrhage. 

Embolism and Thrombosis of the Bulbar Arteries. 

Thrombosis in the region of the medulla oblongata is generally 
dependent upon syphilitic endarteritis ; while embolism is usually asso- 



DISEASES OF THE MEDULLA OBLONGATA. 845 

ciated with disease upon the left side of the heart. Vascular obstruc- 
tion thus caused produces softening of the tissues in the obstructed 
territory, and leads to the development of symptoms which resemble an 
acute or apoplectiform bulbar paralysis. Death may occur suddenly, or the 
symptoms of an apoplectiform or epileptiform seizure may be exhibited ; 
though in cases of circumscribed capillary obstruction, the signs of 
disorder may be limited to vertigo and vomiting, which may be followed, 
however, by progressive weakness and ultimate paralysis. Paralytic 
symptoms may involve the extremities alone, or the bulbar nerves, or 
both may be simultaneously affected. The character and extent of the 
paralytic phenomena obviously depend upon the position and extent of 
the obstruction in the course of the circulation. Gradual recovery may 
result from the establishment of new paths for the circulation; or 
secondary degeneration may extend into the pyramidal tracts of the 
spinal cord, producing contractures and exaggeration of the tendinous 
reflexes in the extremities, a condition that differs from amyotrophic 
lateral sclerosis only in its sudden origin and in the absence of subse- 
quent muscular atrophy. Obviously the location of the disease occasions 
great danger to life. 

Acute Inflammation of the Medulla Oblongata — Myelitis Bulbi 
Rachitici Acuta. 

This rare disease is marked by the occurrence of red inflammatory 
softening in disseminated foci irregularly distributed through the 
substance of the medulla oblongata, producing symptoms of acute 
apoplectiform bulbar paralysis, with or without paralysis of the ex- 
tremities, and causing death, preceded by symptoms of asphyxia, in 
the course of from four to ten days. The existence of the disease may 
be suspected when the symptoms of acute bulbar paralysis are developed 
with moderate fever, and without evidences of hemorrhage, embolism, 
or compression of the medulla. 

Bulbar Tumors — Neoplasmata Medullae Oblongata. 

Tumors involving the medulla oblongata are usually of a tubercular 
character, but all the other varieties of neoplasm have been observed. 
They produce general symptoms which are dependent upon increase of 
pressure within the cavity of the cranium, viz. : vomiting, vertigo, 
choked disc, loss of vision, and epileptiform convulsions. The local 
symptoms consist at first of the evidences of irritation of the bulbar 
nerves, which condition is finally succeeded by their paralysis. The 
consequent nervous disorders develop in the form of strabismus depen- 
dent upon paralysis of the sixth nerve, together with paralysis of the 
muscles of the face, tongue, fauces, pharynx, and larynx, with which 
are associated disorders of hearing, respiration, and circulation. Ob- 
stinate hiccough, sensory, and motor paralysis in the extremities and 
body, polyuria, and saccharine diabetes have also been observed. Some- 
times conjugated deviation of the eyes, and lateral rotation of the head, 
are produced in consequence of interruption of the tegmentary fibres 



M diseases -7 z^z spinal 3<>e: .-. y : :-:e:-:z eaxbs. 

that connect the corpora quadrigemina and the rotator muscles of the 

with each other. It is often impossible accurately : Liagn sti- 

lise 96] since tumors in the neighborhood may produce com- 

pi —ion of the meduli _ ata. P bar paralysis may 

be differentiated by the absence : genei cerebral symptoms. The 

- ect : :n c^y unfavorable, except, perhat i 

cases of syphilitic orig 

Injuries and Compression of the Medulla Oblongata. 

7 "ics if flu Ua oblongata usually produce immediate death. 

In certain cases compression may be suddenly produced by fractures. 
or by lislocation jf the upper cervical vertebrae. Tubercular diseases 
of the mes :: tissues in the neighborhood ma; gradual com- 

pression of the bui": ; and similar results follow die _: th of turn::- w 
the occurrence of arthritis deformans in the upper cervical articulations. 
The symptoms take, at ~: ; :. the character of irritation of the bulbar 
nerves, which is finally merged in the phenomena of paralysis. 
symptoms admit ::" easy recognition, but their precise cause is not 
always apparent before death and autopsy. 



PART XII. 

DISEASESIOF THE SYMPATHETIC NERVES 
AND OF THE MUSCLES. 



CHAPTEE I. 

DISEASES OF THE SYMPATHETIC NERVES. 

Irritation of the cervical sympathetic nerve in the neck is indicated 
by dilatation of the pupils, unusual width of the palpebral fissure, and 
protrusion of the eyeball consequent upon excitement of the nerve fibres 
that are distributed to the dilator muscle of the pupil and to the muscle 
of Muller. Vasomotor disturbances also exist, and are indicated by 
spasmodic constriction of the arteries, producing pallor and coolness 
upon the corresponding side of the face. Sometimes trophic changes 
are indicated by a shrinkage of the tissues in the affected portion. In 
certain cases the cervical ganglia appear sensitive to pressure. 

Irritation of the sympathetic nerve in the neck is usually produced 
by injuries, or tumors that involve the spinal cord, the cervical vertebrae, 
or the tissues in the neck. 

Paralytic conditions of the cervical sympathetic nerve are indicated 
by paralysis of Miiller's muscle and of the dilator muscles of the iris ; 
consequently the pupil is contracted, reacts sluggishly to light, and 
may be oval instead of round in form. The eyeball sinks backward, 
and the width of the palpebral fissure is diminished. The arteries that 
convey the blood to the head and face are dilated and distended, causing 
an increase of color and heat. The secretion of tears, saliva, and per- 
spiration is augmented ; and the temperature is sometimes elevated. 
Trophic changes may be developed after a time. 

Paralysis of the sympathetic nerve may be produced by the same 
causes that are efficient in the production of irritative conditions in the 
nerve. Usually the symptoms of irritation are followed by those of 
paralysis, and frequently the two different states alternate with each 
other. 

The treatment of irritation and paralysis of the sympathetic nerve 
depends upon their causes. The galvanic current may be used with 
great advantage. When it is desirable to quiet irritation, the anode 
should be placed over the sympathetic ganglion in the side of the neck 



848 DISEASES OF SYMPATHETIC NERVES AND MUSCLES. 

below the angle of the jaw, while the cathode is placed upon an indif- 
ferent portion of the body. In paralytic conditions the position of the 
electrodes should be reversed. 

Hemicrania. 

Etiology. Hemicrania (migraine) is usually experienced by females 
during the period of youth and middle life. The disease is frequently 
of an hereditary character, or it may be developed as a consequence of 
exhaustion after over-exertion or debilitating diseases. It is often asso- 
ciated with hysteria, gout, and rheumatism, and it may recur during 
pregnancy or as a symptom of latent renal disease and uraemia. Dis- 
orders of digestion, constipation, and menstruation are frequent ex- 
citants of the disease. It has also been ascribed to various reflex causes 
involving the nasal and pharyngeal passages. 

Symptoms. An attack of hemiorania sometimes commences suddenly, 
but it is often preceded by sensations of vague discomfort and disturb- 
ance of the cerebral functions. In certain cases the patient awakens 
with headache, but it often comes on during the forenoon and only 
ceases after the occurrence of sleep during the following night. The 
paroxysm rarely continues more than one day. The character of 
the pain is usually dull and heavy. Sometimes it is increased by 
every pulsation of the heart. It is more severe upon one side of 
the head than upon the other, and it is often circumscribed within 
still narrower limits. The occipital region generally escapes, while 
the forehead and vicinity of the eye is the favorite seat of suffering. 
Pressure-points do not exist, but frequently the skin is excessively 
sensitive to slight pressure or to contact with the hair, though deep 
pressure usually gives a certain amount of relief. Light and sound be- 
come intolerable, nausea and vomiting are not uncommon, and some- 
times the bowels and kidneys are considerably relaxed. 

Two forms of the disease have been described. They differ princi- 
pally through opposite conditions of the cervical sympathetic nerve. 
Spastic hemicrania is associated with the symptoms of irritation involv- 
ing the cervical portion of the sympathetic nerve, producing contraction 
of the bloodvessels, while paralytic hemicrania is accompanied by the 
symptoms of its temporary paralysis, indicated by vascular relaxation. 
In many cases the symptoms of irritation attend the commencement of 
the attack, and after a time give way to the evidences of paralysis. 

Hemicrania is frequently a lifelong disease; but among women it 
often ceases at the menopause, and under all circumstances the parox- 
ysms usually become less severe and less frequent at an advanced age. 

Treatment. Though it is often impossible to effect a complete re- 
moval of the disease, its severity may be diminished by general treat- 
ment that is calculated to improve the health and to remove those causes 
of a depressing nature by which the nervous system is predisposed to 
disease. Each case affords a large opportunity for experiment with 
restorative remedies, and the effects of change of air cannot always be 
foreseen. Some patients are benefited by residence at the seaside, while 
others are much more favorably affected by mountain air. The greatest 



DISEASES OF THE SYMPATHETIC NERVES. 



849 



benefit is often derived from gentle stimulation of the bowels and kid- 
neys. Electricity is often useful, and may be employed according to 
the rules for the treatment of sympathetic irritation and paralysis. 
During the paroxysm the patient finds relief in the recumbent position 
in a dark and quiet room. When symptoms of indigestion are promi- 
nent, a blue pill, followed by a Seidlitz powder, or the action of an emetic, 
often give relief. When cerebral symptoms take the lead the headache 
frequently is relieved by large doses of salicylic acid, acetanilide, or 
phenacetine. When paralysis of the sympathetic nerve exists, caffeine, 
guarana, strychnine, and quinine are useful. A combination of caffeine 
and the bromides often gives great relief, but sometimes it is necessary 
to administer a full dose of laudanum. Opiates should be prescribed 
with the greatest caution, for fear of establishing the opium habit. 
Transient relief is frequently obtained from the application of mustard 
to the back of the neck, or other stimulants, like veratrine, menthol, or 
the oil of peppermint, to the forehead and temples. 

Progressive Facial Hemiatrophy— Hemiatrophia Facialis Progressiva. 

Etiology. For this rare disease no uniform cause is known, 
though it has been observed after injuries, after infective diseases, and 
after exposure to cold. (Fig. 159.) 

Fig. 159. 




Facial hemiatrophy. (Rush Medical College Clinic.) 



Symptoms. Facial hemiatrophy is characterized by progressive 
atrophy of the skin, subcutaneous tissues, muscles, bones, gums, and 
tongue upon one side of the face. The disease develops gradually with 
various perversions of sensation in the affected part. The hair becomes 
thin and sometimes changes color. Brownish spots appear upon the 
face and gradually extend, becoming more or less confluent. The sub- 
jacent fat disappears, the skin grows thin and is depressed, forming 
deep furrows that correspond with the outlines of the discolored patch. 

54 



850 DISEASES OF SYMPATHETIC NERVES AND MUSCLES. 

The eye upon the affected side appears sunken, and the corner of the 
mouth is sometimes slightly drawn open by the contracted tissues. The 
nostril may be also similarly deformed, so that the face appears twisted 
toward the affected side. Sensation, temperature, and perspiration are 
not affected, but the function of the sebaceous glands is usually dimin- 
ished. The bloodvessels exhibit nothing abnormal, and the circulation 
of blood experiences no change In severe cases the muscles and 
bones upon the affected side participate in the atrophic process. Ttie 
cartilages of the nose and ear are also involved in a similar manner, 
and sometimes the corresponding half of the tongue and of the ft 
exhibit the same changes. The muscular fibres are reduced in size, but 
their electrical reactions are usually unchanged. Sometimes the sense of 
taste is somewhat reduced upon the affected side, but the other special 
senses seldom suffer. Symptoms of irritation in the territory of the 
cervical sympathetic nerves are occasionally witnessed, and in rare in- 
stances both sides of the face undergo atrophy. The disease is exceed- 
ingly chronic, but is not attended with danger to life. 

In a few instances hemifacial hypertrophy has been observed. It 
is a congenital condition involving the soft parts of the face, ear. ton- 
sils, and tongue. The skin is darkly discolored, the sebaceous follicles 
are enlarged, and the hair grows more abundantly than upon the 
healthy side. The deformity frequently involves the other structures 
upon the same side of the body. 

Acromegaly— Akromegalia. 

Acromegaly is characterized by an inordinate and morbid growth of 
the extremities and under jaw. It is a rare disease, and nothing is 
known regarding its causes. It is usually developed after the age of 
puberty, and is often preceded by vague symptoms of headache, and 
other forms of pain in the extremities. Gradually the hands and feet 
grow larger and more clumsy. An expression of distress is developed 
upon the countenance, indicating the state of depression into which the 
patient is brought. The skin and the muscles do not share in the pro- 
cess, but the nails become incurved or unusually flattened and brittle. 
The patella? share in the osseous enlargement, and the legs resemble 
those of patients afflicted with elephantiasis. The thighs and the upper 
arms are but slightly changed. The lower jaw becomes unusually large 
and prominent, though the teeth remain unchanged. The lower lip is 
thickened, and the nose is greatly enlarged. The eyebrows become 
unusually prominent, and the eyelids are thickened. Sometimes the 
ears also become enlarged and pointed. In certain cases the bones of 
the thorax, the collar bone, and the shoulder-blade share in the general 
deformity. The head bends forward and seems to sink between the 
enormous shoulders until the chin rests upon the sternum. The inter- 
nal organs sometimes are enlarged. The thyroid gland is frequently 
atrophied, though the thymus gland is occasionally enlarged. Cuta- 
neous sensibility and the electrical reactions of the nerves and muscles 
remain unchanged. The sexual functions cease, but the other appetites 



DISEASES OF THE SYMPATHETIC NERVES. 851 

are often exaggerated, and the mind exhibits evidences of progressive 
weakness. 

The disease is often very rapidly developed, and its duration is pro- 
tracted for many years. Death usually results from intercurrent dis- 
eases or from exhaustion. Aside from the changes which have been 
already described nothing has been discovered to account for the disease. 
The sympathetic ganglia have been found in a state of enlargement, 
and the hypophysis cerebri is almost always enlarged ; but since nothing 
is known regarding the functions of this organ the fact throws no light 
upon the pathology. 

The diagnosis of acromegaly is usually easy, since the inflammatory 
diseases by which the extremities are sometimes deformed (osteitis de- 
formans and arthritis deformans) are accompanied by pain and other evi- 
dences of acute disease in the joints and bones. Elephantiasis and myxe- 
dema can be differentiated by the fact that the bones do not participate 
in the deformity w r hich they produce. Leontiasis ossea involves the 
bones of the cranium alone. 

Myxcedema. 

Myxoedema is characterized by three cardinal symptoms : solid 
oedema, cachexia, and nervous derangement. 

The features become universally disfigured by an oedematous swell- 
ing which also involves the extremities and the body, and invades 
the mucous surfaces. The skin is pale, cool, and waxy, and does 
not pit on pressure, since it and the subcutaneous tissues are 
infiltrated with mucin. Sometimes the surface appears livid, and the 
general temperature of the body is considerably depressed. The 
pulse is retarded, the appetite disappears, the bowels become consti- 
pated, the urine is albuminous, blood is extravasated into the retina and 
other tissues. The voice becomes rough and otherwise unnatural, the 
patient sinks into a state of exhaustion, apathy, and somnolence, some- 
times accompanied by delirium and other evidences of mental disturb- 
ance. 

The disease is chronic and often continues for many years. Endar- 
teritis and other morbid changes have been observed in other organs 
of the body, but the nervous system usually exhibits no signs of disease. 
A similar condition has been experimentally produced in monkeys by 
extirpation of the thyroid gland ; and it has been also observed after 
operation necessitated by thyroid enlargement in the human subject. 

Good diet and general symptomatic treatment, together with mas- 
sage and electricity, afford the most favorable results. Pilocarpine has 
been recommended to stimulate the functions of the skin when they are 
deficient and albuminuria is present. 

Erythromelalgia. 

Erythromelalgia is a vasomotor neurosis involving the extremities, 
and corresponding to the analogous spastic and paralytic conditions 
that are dependent upon irritation and paralysis of the cervical portion 



852 DISEASES OF SYMPATHETIC XERVES AND MUSCLES. 

of the sympathetic nerve. The spastic form of the disease is most fre- 
quently observed among women, especially among washerwomen who 
are compelled to keep their hands for a long time immersed in cold 
water. It is characterized by burning and painful sensations, com- 
mencing in the fingers and toes and extending up the limbs. The 
volume of the pulse is diminished, the skin becomes cold and pale, or 
cyanosed, and is sometimes covered with clammy perspiration. Some- 
times the extremities appear somewhat swelled and stiffened, and the 
skin loses a portion of its sensitiveness to external impressions. The 
paroxysms occur more frequently during cold weather, at which time 
they are sometimes numerous and prolonged, and may be easily excited 
by exposure. 

The paralytic form of ery thro melalgia is usually experienced by men 
during middle life. It is sometimes preceded by rheumatism or by 
exposure to cold and unusual fatigue. It has been sometimes observed 
among artisans who were employed in the working of copper. The 
disease is manifested in paroxysms of severe pain in the extremities. 
Sometimes there is no change of color, but usually the skin becomes 
flushed and warm over the affected portion. Hot weather and exposure 
to heat cause an increase of suffering, so that the patient usually lies 
with his feet uncovered at night. Unlike the spastic form, the para- 
lytic variety usually attacks the feet rather than the upper extremities. 

The treatment requires attention to the general health, together with 
a careful search for special causes of nervous irritation or exhaustion. 
Electrical treatment affords the best results. Local applications, ano- 
dyne liniments, etc., only yield temporary relief. 

Intermittent Articular Dropsy. 

Intermittent swelling of the joints, most frequently observed in the 
knee-joint, has been occasionally described. The cavity of the joint 
remains distended for about a week without the existence of any inflam- 
matory symptom or pain. Swelling then subsides, and after an inter- 
mission of a week or longer, it is again renewed. In this way the 
disease may be prolonged for many months or years. Nothing is 
known regarding its causes. It has been treated with anti-periodics, 
ergot, and electricity. 

Intermittent Angioneurotic (Edema. 

This disease is sometimes hereditary, and it is more frequently 
observed among neurotic patients of the male sex than among females. 
It is sometimes associated with menstruation and the menopause, and 
it is not uncommonly caused by exposure to cold or by rheumatism and 
alcoholism. It is characterized by disordered conditions of the alimen- 
tary canal and by the paroxysmal occurrence of circumscribed patches 
of oedema upon the surface of the skin and mucous membranes. Some- 
times the affected parts exhibit no change of color, but they may be 
either unusually pale or flushed. The disease most frequently involves the 
neighborhood of the joints upon the extremities, but it sometimes 
appears upon the face or occasions swelling of the joints themselves. 



DISEASES OF THE MUSCLES. 853 

The paroxysm seldom lasts more than a few hours, but it may be often 
repeated during many months or years. In certain cases it occasions 
the symptoms of acute oedema of the glottis, necessitating scarification 
of the parts. Ordinary cases are relieved by attention to the condition 
of the digestive organs and kidneys. 

Symmetrical Gangrene. 

Symmetrical gangrene (Raynaud's disease) is usually observed among 
anaemic, enfeebled, and nervous women. It may be excited by the 
ordinary causes of nervous disease. It sometimes follows influenza and 
the infective diseases, and may be attended by swelling of the spleen 
as if it were itself produced by an infective cause. In certain cases it 
is dependent upon peripheral neuritis or upon other diseases involving 
the brain and spinal cord. 

The fingers and toes are the usual seat of the disease, but it some- 
times attacks the tip of the nose or the rims of the ears. Less frequently 
does it occur elsewhere. The skin becomes pale, cold, and cyanotic. 
Sometimes the pulse can be no longer felt. The epithelium becomes 
blistered and elevated by bullous eruptions that are soon followed by the 
development of gangrene. The symmetrical character of the process 
is worthy of remark. In many cases the fingers and toes are destroyed, 
and patches of superficial gangrene sometimes develop elsewhere. The 
process is often accompanied by high fever and other symptoms of 
violent inflammation, but usually life is preserved and recovery com- 
mences in the course of two or three weeks. 

Symmetrical gangrene has been ascribed to the existence of vascular 
spasm and consecutive local asphyxia, but it is probably dependent in 
many cases upon other diseases. In certain instances a peripheral neu- 
ritis, or an inflammation of the arteries and veins has been discovered. 

The treatment must be largely symptomatic and surgical. During 
convalescence tonics and restoratives should be prescribed. 



CHAP TEE II. 

DISEASES OF THE MUSCLES. 

Pseudo-muscular Hypertrophy— Pseudo-Hypertrophia Musculorum. 

Etiology. Pseudo-muscular hypertrophy is usually observed before 
the fifteenth year. It is more frequent among males than among 
females. It is often dependent upon hereditary causes. It is more 
commonly transmitted by the mother than by the father, because male 
patients are seldom capable of contracting matrimony, while the disease 
may be inherited through the maternal parent, who remains herself 
unaffected, and consequently capable of contracting marriage. The 
disease sometimes follows the infective diseases, and it has been encoun- 



854 DISEASES OF SYMPATHETIC NERVES AND MUSCLES. 

tered among juvenile victims of alcoholism. It is frequently excited 
by injuries, or by exposure to wet and cold ; and it is often associated 
with idiocy and other evidences of defect or disease in the nervous 
system. 

Symptoms. Pseudo-muscular hypertrophy is chiefly characterized 
by the increase in size of certain muscles which, at the same time, 
diminish contractile power, while other muscles simultaneously undergo 
atrophy and progressive weakness. The disease is sometimes congeni- 
tal, but under other circumstances it gradually develops. Muscular 
exercise is attended with fatigue and some degree of pain. Such 
children cannot walk until they are four or five years of age, and they 
move with an uncertain gait. Gradually the muscles in the calf of the 
leg become conspicuous by their size, then follow the extensor muscles 
of the thigh and the gluteal muscles. As these changes progress the 
muscles of the back and of the upper extremity become atrophied, so 
that with the lower limbs of an athlete are associated the body and 
upper extremities of a starveling. Occasionally the upper part of the 
body, the face, and the tongue participate in the hypertrophic process. 

The power of locomotion fails as the process advances. The toes are 
liable to drag, the gait is waddling, the lumbar vertebrae are thrown 
forward, while the upper dorsal vertebrae project backward. ( It 
becomes difficult to sit down, since the body tends to fall helplessly 
upon its seat ; and when the patient is placed upon the floor he can 
only get up through great exertion, supporting the body by placing the 
hands first upon the knees and then slipping them one after the other 
up the thighs as he rises from the floor, thus literally climbing up his 
own lower extremities. 

Muscular contractures are sometimes developed in the lower limbs, 
and the foot may assume the varo-equinus position. Fibrillary contrac- 
tions and the reaction of degeneration are not observed. The electrical 
excitability of the muscles diminishes as they dwindle. The muscular 
mass becomes enlarged, firm, and hard as a consequence of the prolifer- 
ation of its connective tissues. When fat is abundantly deposited in 
that tissue, it imparts a tallowy sensation to the hand by which it is 
compressed. Sometimes the muscles are sensitive to pressure, and the 
mechanical excitability very gradually disappears. The skin over the 
affected muscles becomes blue and cold, but its sensibility remains un- 
changed. There is diminution of perspiration, and inflammation is 
easily excited upon the surface in consequence of trophic and secretory 
disorder. The subcutaneous connective tissue frequently becomes 
loaded with fat, and the patellar reflex finally disappears. The general 
health is long preserved. Sometimes idiocy and imbecility exist. Pul- 
monary and cardiac diseases are easily excited, and are not uncommon 
causes of death. The bowels are evacuated with difficulty by reason 
of muscular weakness, but the bladder undergoes no disturbance of 
function. 

The duration of the disease is chronic, in many cases lasting for more 
than twenty years. 

Pathological Anatomy. The brain, spinal cord, and sympathetic 
nerves exhibit no morbid changes. Such interstitial degeneration as 



DISEASES OF THE MUSCLES. 855 

may be sometimes discovered in the peripheral nerves is only an acci- 
dental consequence of disuse. The muscular tissues appear yellow, and 
sometimes can scarcely be differentiated from adjacent masses of fat. 
The disease involves the muscular fibres, which gradually dwindle and 
undergo fatty or other forms of degeneration, and are replaced by in- 
terstitial connective tissue which, in its turn, undergoes extensive infil- 
tration with fat. 

Diagnosis. Pseudo-muscular hypertrophy can be readily differenti- 
ated from spinal progressive atrophy by reference to the origin and 
course of that disease, and by the apparent enlargement of the muscles. 
Acute anterior poliomyelitis commences suddenly, and the paralyzed 
muscles exhibit the reaction of degeneration. Myelitic paralysis, accom- 
panied by accumulation of fat, presents a much higher degree of paral- 
ysis, and it is developed more rapidly before the muscles become 
overladen with fat. 

Prognosis and Treatment. The disease, though not immediately 
dangerous to life, is probably never healed. Its course may be retarded 
by massage and by the application of electricity to the affected muscles. 
Internal remedies produce no appreciable effect. In many cases ortho- 
paedic assistance will be found necessary. 

Juvenile Progressive Muscular Atrophy — Atrophia Musculorum 
Progressiva Juvenilis. 

Etiology. Myopathic atrophy tends to assume a variety of forms 
invading sometimes this, sometimes that group of muscles. The juvenile 
form above indicated is characterized by muscular weakness, due to atrophy 
of the muscular fibres, caused by increase of the interstitial connective 
tissue. This, in some cases, is sufficient to produce apparent enlarge- 
ment of certain muscles, though without the accumulation of fat which 
characterizes pseudo-muscular hypertrophy. The disease is largely 
dependent upon hereditary influences, and it is developed during child- 
hood or early youth, among females as well as among the opposite sex. 

Symptoms and Diagnosis The most characteristic symptom of 
the disease consists in the parallel extension of muscular atrophy with 
apparent muscular hypertrophy. The atrophic process commences 
in the back, shoulder, upper arm, and supinator longus. The lower 
portion of the body, the thigh, and the tibialis anticus muscle are 
affected at a later period. The muscles of the forearm, hand, and call 
of the leg escape entirely, or are involved at a late period only, and 
furnish a striking contrast to the atrophied muscles nearer the body. 
The following muscles usually escape disease : The muscles of the face 
and of mastication, the ster no- cleido- mastoid, levator anguli scapulce, teres 
major, teres minor, supra- and, infra- spinatus, coraco-brachialis, and 
deltoid ; that is, the group of muscles by which the arm is raised and 
rotated at the shoulder. In the lower extremity the sartorius muscle 
and the muscles in the calf of the leg also escape. These groups undergo 
hypertrophy, and stand out under the skin with a prominence that is 
doubly conspicuous by reason of the atrophy that has invaded their fel- 
lows. The mechanical and electrical excitability of the muscles, the 



856 DISEASES OF SYMPATHETIC NERVES AND MUSCLES. 

tendinous reflexes, and the condition of the sphincters correspond with 
what has already been described in pseudo- muscular hypertrophy. 
Sensory disorders said fibrillary contractions do not occur. The course 
of the disease is coextensive with life, and death results after many years 
from exhaustion or from intercurrent diseases. 

Pathological Axatomy. The principal changes are observed in 
the muscular fibres. They become hypertrophied, vacuolated, and 
finally atrophied, while the connective tissue is only moderately in- 
creased, and fatty infiltration does not occur. 

Treatment. Medication is useless, and the only treatment that is 
of any service consists of massage and the use of electricity. 

Another form of juvenile progressive myopathic atrophy has been 
described, in which the hereditary influences and the general course of 
the disease are identical with the preceding forms, but the muscles of 
the face participate in the process, giving a peculiar expression to the 
countenance and interfering with the movements of the eyelids and 
lips. The muscles of mastication, together with the muscles of the 
tongue, fauces, and larynx, remain unchanged. The majority of the 
muscles in the back and in the extremities are also involved, with the 
exception of the sub-scapular, supra- and infra- spinatus muscles, and 
the flexors of the hand and fingers. Hypertrophy of muscular fibres 
and the accumulation of fat do not take place. The muscular fibres 
undergo simple atrophy, accompanied by very moderate proliferation of 
the connective tissue. The spinal cord and the peripheral nerves remain 
perfectly healthy. 

In certain rare cases the voluntary muscles undergo true hypertrophy, 
without any of the accompanying changes that characterize pseudo- 
muscular hypertrophy. The process is gradually developed, and is 
accompanied by a certain amount of neuralgic pain and other perver- 
sions of sensation. The vigor of the affected tissues is diminished, and 
sometimes idiocy is manifested. The prognosis is grave, since the 
patient becomes more and more enfeebled. The same management is 
required as in pseudo-muscular hypertrophy. 

Progressive Muscular Ossification — Myositis Ossificans Progressiva. 

This rare disease usually commences during childhood, and its causes 
are unknown. It is a very chronic disorder, continuing for many 
years. It is characterized by symptoms of pain and inflammation, 
usually commencing in the muscles of the back, neck, and shoulders, 
whence it may extend to many of the muscles of the face and extremi- 
ties. As the disease progresses the muscles appear to be invaded by a 
tumefied mass which, after a time, may disappear, but which sometimes 
occasions induration and contraction of the muscles, and finally results 
in its ossification. Sometimes the newly formed osseous mass becomes 
adherent to the subjacent bones, which in their turn frequently develop 
multiple exostoses. The effect of these changes is marked by very 
notable deformity and loss of function in the invaded muscles. The 
limbs consequently become stiffened, and locomotion is seriously im- 



DISEASES OF THE MUSCLES. 857 

peded. Occasionally ossified masses undergo degeneration and are 
reabsorbed. 

Treatment. The ordinary treatment of local inflammation is in- 
dicated at the commencement of the disease. As the acute symptoms 
subside iodide of potassium should be administered internally, together 
with daily warm baths and cautious manipulation of the affected mus- 
cles, which may also be rubbed with mercurial or iodoform ointment. 
Various alteratives may be prescribed as required. 

Acute Multiple Muscular Inflammation — Polymyositis Acuta. 

Nothing is known regarding the causes of this disease. It begins 
with fever and pain involving the back and limbs, sometimes associated 
with rheumatic swelling of the joints, but chiefly affecting the muscles 
of the body and extremities. They become swelled, tense, and painful 
on pressure. The overlying skin is tense and cedematous, The ten- 
dinous reflexes are abolished in the affected parts, but the electrical ex- 
citability of the muscles remains without change, and the nerve trunks 
are not sensitive to pressure. As the disease improves in one muscle, 
it is liable to grow worse in another. Death may occur as a conse- 
quence of invasion of the respiratory muscles. Microscopical exami- 
nation reveals the symptoms of inflammation in the interstitial tissue, 
with waxy or fatty degeneration of the muscular fibres. The nervous 
system remains unchanged. 

The disease differs from polyneuritis in the fact that the nerve trunks 
are not sensitive to pressure, and that the electrical excitability of the 
muscles is preserved. In many respects the disease resembles trichi- 
nosis, but it may be distinguished by the absence of the parasite. The 
prognosis is not favorable. During the early stage of the disease the 
ordinary methods of antiphlogistic treatment are required, together 
with the use of salicylic acid. After the subsidence of acute symptoms 
gentle massage and faradization will be found useful. 



PART XIII. 

DISEASES OF THE BRAIN AND CEREBRAL 
MEMBRANES. 



CHAPTER I. 

DISEASES OF THE CEREBRAL MEMBRANES. 

Thrombosis and Inflammation of the Cerebral Sinuses— Thrombosis 
et Phlebitis Sinunm Durae Matris Cerebri. 

Etiology. Thrombosis frequently exists as a consequence of in- 
flammation of the cerebral sinuses, but it may also arise in the course 
of chronic, wasting, or malignant diseases. In such cases the disease 
usually involves the superior longitudinal sinus or the transverse sinus. 

Occasionally thrombosis is caused by direct pressure upon the sinuses, 
or by compression of the veins in the neck, or as a consequence of ob- 
struction to the return of blood into the thoracic vessels. Inflammatory 
and tubercular processes within the cranium, and the existence of 
injuries, wounds, or infective diseases involving the scalp and the face, 
are frequently followed by the formation of thrombi in the sinuses of 
the brain. 

Pathological Anatomy. In thrombosis of the sinuses their cavity 
is occupied by an imperfectly organized coagulum, of a brown or gray 
color, which differs widely from the simple blood clots that are frequently 
discovered in the sinuses after death. The partially organized structure 
is somewhat adherent to the vascular walls, and it frequently extends 
into the veins that communicate with the cavity in which it has its 
origin. The obstructed veins are obviously distended with blood ; and 
sometimes meningeal hemorrhages occur, or the cerebro-spinal fluid 
appears stained with haemoglobin. Sometimes fragments of a thrombus 
are carried into the circulation, and reach the lungs, where they pro- 
duce embolism and its usual consequences. 

When thrombosis occurs as a secondary consequence of inflammation 
in the walls of the sinuses, the various products of inflammation are 
associated with its development ; and if the inflammatory process be 
accompanied by the transportation of infective masses into the lungs, 
suppuration and pyaemia will be developed within the thorax and else- 
where. 



860 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

Symptoms and Diagnosis. Thrombosis of the sinuses frequently 
exists without characteristic symptoms, but frequently it is accompanied 
by the usual evidences of meningitis, to which may be sometimes added 
the phenomena of pulmonary embolism or of pyaemia. 

Thrombosis of the superior longitudinal sinus is indicated by disten- 
tion of the superficial veins which cross the top of the head. The 
fontanelle in infants is at first depressed, but at a later period it is 
distended by the accumulation of cerebro spinal fluid. 

In thrombosis of the transverse sinus the external jugular vein appears 
collapsed, since it discharges its blood more readily into the empty in- 
ternal jugular vein. (Edema is sometimes developed behind the ear. 

Thrombosis of the cavernous sinus sometimes produces stagnation of 
the blood in the ophthalmic veins, oedema of the eyelids, exophthalmus 
by reason of the distention of the retro-bulbar veins, venous hyperemia 
of the retina, choked disc, amblyopia, and sometimes an oedematous 
swelling of the corresponding half of the face. The ocular muscles and 
the trigeminal nerve also undergo compression and irritation, or paral- 
ysis. Trophic changes may also occur in the eye. 

Thrombosis of the sinuses generally runs its course in a few days. 
Recovery seldom occurs, though the disease is subject to remissions and 
exacerbations. Feverish symptoms are not uncommon, and death re- 
sults from exhaustion. 

Treatment avails nothing. 

Hemorrhagic Pachymeningitis — Pachymeningitis Interna 
Haemorrhagica. 

Pathological Anatomy. In certain cases extravasation of blood 
takes place upon the surface of the dura mater, forming a thin layer of 
coagulated blood that undergoes a partial organization, and is liable to 
gradual increase by repeated extravasations from the newly formed 
bloodvessels. In this way a large quantity of blood and of false mem- 
brane may be accumulated between the dura mater and the surface of 
the brain. The cerebral substance is correspondingly compressed, and 
deprived of blood through pressure Sometimes inflammatory processes 
are associated with the extravasation ; the membranes of the brain be- 
come thickened and adherent to each other, and contain serous or 
purulent accumulations. 

Etiology. Hemorrhagic pachymeningitis is much more common 
among men than among women. It is caused by injuries, by the ex- 
tension of inflammation from the neighboring bones and tissues, bv ex- 
cessive alcoholism, by diseases of the brain, particularly those which 
occasion atrophy of the organ, by disorders of respiration and circula- 
tion, and by chronic wasting diseases, especially when characterized by 
a tendency to hemorrhage. 

Symptoms and Diagnosis. In slight forms of hemorrhagic pachy- 
meningitis symptoms may be entirely absent ; but when the amount of 
extravasation is sufficient to create pressure upon the brain and upon 
its sensitive membranes, symptoms are developed. Among these are 
headache that is sometimes located over the seat of hemorrhage. It is 



DISEASES OF THE CEREBRAL MEMBRANES. 861 

supposed that many of the peculiar and involuntary movements that are 
witnessed during the stupor that characterizes the last stages of certain 
diseases may be ascribed to irritation of the cerebral cortex thus pro- 
duced, e. g., picking at the bedclothes, pawing the air, fumbling the 
genitals, etc. 

More significant, however, are symptoms that indicate increasing 
pressure within the cranium. Such are apoplectiform seizures, and a 
trance-like coma in which the patient sleeps continually, voids urine 
and feces unconsciously, must be fed like an infant, and if aroused 
moves about like one in a dream. The pupils are frequently contracted 
or unequal and sensitive to light. The wider pupil usually corre- 
sponds to the side upon which hemorrhage has occurred. Sometimes 
choked disc and unilateral nystagmus are observed, and more or less 
complete paralysis is frequently developed. In certain cases the symp- 
toms of irritation are prominent and take the form of convulsions and 
contractures, or conjugated deviation of the eyes and head may be wit- 
nessed. Irregularity and retardation of the pulse are frequent, and 
sometimes the temperature is greatly elevated. 

In certain cases the blood is gradually absorbed, and recovery takes 
place ; but the disease is always attended with danger, which increases 
in proportion to the degree of pressure. It is always difficult to recog- 
nize the nature of the cause of the symptoms, since they merely indicate 
an increase of intra-cranial pressure. 

Treatment. Alcohol and other stimulants must be removed from 
the diet of the patient. Sometimes a copious bleeding relieves the 
symptoms of pressure, but this must not be practised except in cases of 
plethora. The general treatment for cerebral hemorrhage is appro- 
priate in cases of hemorrhagic pachymeningitis. 

Meningeal Hemorrhage — Haemorrhagia Meningealis. 

Pathological Anatomy. Hemorrhage may occur into the tissue 
of the meningeal membranes, as may be witnessed in cases of suffoca- 
tion, or it may occur between the meninges, either between the cranial 
bones and the dura mater (epi-dural hemorrhage), between the dura 
mater and the arachnoid membrane (sub-dural hemorrhage), into the 
spongy tissue that occupies the space between the arachnoid membrane 
and the pia mater (sub-arachnoid hemorrhage), or into and beneath the 
pia mater (sub-pial hemorrhage). The extent of such hemorrhages 
may be exceedingly limited, or the extravasation may be so copious 
as to surround the entire circumference of the brain, distend the ven- 
tricles, and completely fill the spinal canal. 

Etiology. Meningeal hemorrhage is usually caused by injuries, 
among which may be specified the consequences of difficult parturition 
and instrumental delivery ; by disturbances of circulation, such as 
occur in consequence of thrombosis in the cerebral sinuses, or from the 
rupture of aneurisms, or from stagnation of the blood dependent upon 
cardiac and pulmonary diseases. Sometimes it occurs in connection 
with convulsive attacks, such as occur during the paroxysms of epilepsy 
and tetanus. In certain cases meningeal hemorrhage results from 



862 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

deteriorated conditions of the blood in the course of infective and hemor- 
rhagic diseases. 

Symptoms and Diagnosis. Slight hemorrhages may occur without 
symptoms. In cases of a convulsive character, in which meningeal 
hemorrhage is discovered after death, it is often impossible to decide 
whether the hemorrhage be the primary cause of convulsion or its 
secondary consequence. 

The asphyxiated condition in which children are sometimes brought 
into the world is frequently due to meningeal hemorrhage. Such 
apoplexia neonatorum may be suspected when the fontanelles remain 
unusually distended after birth. 

The characteristic symptoms of meningeal hemorrhage are most ap- 
parent when it occurs as a consequence of the rupture of an intra- 
cranial aneurism. The usual symptoms of an apoplectic seizure are 
then developed, and death may follow in a very short time. Recovery 
can only occur in cases of very moderate extravasation. 

Treatment. Epi-dural hemorrhage can sometimes be relieved by 
opening the cranium with the trephine ; but if this operation be not 
indicated, the ordinary treatment for cerebral hemorrhage must be 
employed. 



CHAPTEE II. 

DISEASES OF THE BRAIN. 

Preliminary Considerations. 

Diseases within the cranium are characterized by local symptoms 
and by general cerebral symptoms. The general symptoms merely 
signify disorder of the cerebral functions. They consist chiefly of 
vertigo, disorder of sensation and of the intellectual functions, perver- 
sion of the special senses, vomiting, and modification of the circulation. 

Local symptoms are dependent upon definite local changes in the 
brain. They are characterized by the phenomena of irritation, or of 
paralysis. Local and general symptoms are frequently associated to- 
gether. 

Local symptoms may be either transitory or permanent, direct or 
indirect. Direct sympto?ns obviously are the immediate result of local 
changes, but indirect symptoms are those which depend upon remote 
changes in regions with which the organs in which symptoms appear 
are only indirectly connected. Thus hemianopsia may be the direct 
result of a definite local lesion in the optic tract or occipital lobe, or it 
may be the indirect consequence of a local disease in the thalamar por- 
tion of the brain. 

Local symptoms of diseases of the cerebral cortex. The motor- 
functions of the cerebral cortex chiefly concern the anterior and pos- 



DISEASES OF THE BRAIN. 



863 



terior central convolutions and paracentral lobule. The symptoms of 
disease in this territory depend upon the character of the disturbance, 
whether it be irritating or paralyzing. Irritative lesions produce mus- 
cular spasms, while destructive lesions of the cortex produce muscular 




lobe 



TEMPORAL 



Diagram of the gyri (convolutions) and sulci (fissures) on the lateral surface'of the 
right hemisphere of man. (Gowers.) 

Fig. 161. 

W°-JL-E__ X Rolando 




7*£: M poaM- w 

The same on the mesial surface. (Gowers.) 

paralysis. A combination of these symptoms indicates the concur- 
rence of irritative and destructive processes in the cortical territory. 

The extent to which these symptoms may involve the muscular 
apparatus of the body depends upon the extension of disease in the cor- 
tical region. When the motor centres in the paracentral lobule and the 
central convolutions are all involved in the process of destruction, com- 
plete hemiplegia is the result. Circumscribed lesions are followed by 



864 DISEASES OF BRAIX AND CEREBRAL MEMBRANES. 

correspondingly restricted symptoms, and monoplegic paralysis may 
thus be developed either in the leg, in the arm, or in the facial region. 
The frontal branch of the facial nerve, however, escapes paralysis, so 
that the eyelids may be closed, as they cannot be in peripheral paralysis 

Fig. 162. 




Te.U 



The lateral surface of the right cerebral hemisphere of man in outline, to illustrate 
the cortical areas. Reduced from nature. (Foster.) 

Fig. 163. 



Fr.L 




Te.L 

The mesial surface of the right cerebral hemisphere of man in outline, to illustrate 
the cortical areas. (Foster.) 



of the facial nerve. Such phenomena frequently result from injuries of 
the brain, or from embolism or thrombosis of the Sylvian artery, and 
are often followed by descending degeneration of the pyramidal tracts, 
occasioning contractures of the muscles and exaggeration of the tendi- 
nous reflexes in the extremities. When recovery takes place, it is 
usually more perfect in the lower limb than in the upper. (Figs. 160, 
161, 162, 163.) 



DISEASES OF THE BRAIN. 865 

The motor centres for the muscles are situated in the paracentral 
lobule and central convolutions, and are grouped as follows : 

1. The cortical motor centre for the hypoglossal nerve occupies the 
lower portion of the anterior central convolution. 

2. The cortical centre for the facial nerve lies in the lower third of 
the anterior central convolution. 

3. The cortical centre for the arm occupies the middle third of the 
anterior, and perhaps of the posterior, central convolution. 

4. The cortical centre for the leg occupies the upper two-thirds of the 
posterior central convolution, the upper third of the anterior central 
convolution, and the paracentral lobule. 

Irritation involving these motor centres produces muscular contraction 
or spasm corresponding to the extent and intensity of the irritation. In this 
way epileptiform convulsions, with or without loss of consciousness, may 
be excited. They differ from ordinary epileptic attacks in the situation 
and nature of their cause, and constitute what is termed cortical epilepsy. 
Similar epileptiform spasms are frequently associated with symptoms of 
cortical paralysis, and are generally developed subsequently to the 
appearance of the paralytic phenomena. 

From the preceding considerations it appears that cortical diseases of 
the brain involving the motor centres may produce : 

1. Monoplegia without the reaction of degeneration, since the spinal 
trophic centres remain intact. 

2. Hemiplegia associated with oculo-motor paralysis, contracture, 
and exaggerated tendinous reflexes dependent upon secondary degenera- 
tion in the pyramidal tracts. 

3. Transformation of monoplegia into hemiplegia, through the 
extension of cortical diseases from one motor centre into another motor 
centre. 

4. Epileptiform spasms or convulsions that are always restricted to 
certain groups of muscles, and are only occasionally followed by loss of 
consciousness. 

5. A combination of paralytic and spasmodic symptoms in particular 
groups of muscles, or even assuming a hemiplegic character. 

Since the central convolutions (motor zone) furnish an intermediate 
station between other portions of the brain and the paths of voluntary 
impulse to the muscles, their motor centres may be excited by disturb- 
ances or diseases in other portions of the cerebral cortex. Diseases of 
the frontal lobe may thus produce disturbances of speech which are in- 
dicated by the term aphasia. Lesions of the foot of the third frontal 
convolution are followed by motor or ataxic aphasia. Diseases of the 
cortical portion of the first convolution of the temporal lobe produce 
disturbances of hearing, which may be associated with sensory aphasia, 
or word-deafness. Diseases of the parietal lobe are followed by loss of the 
muscular sense, so that when the eyes are closed it is impossible for the 
patient to determine the position of his limbs. In the lower portion of 
the parietal lobe is situated a centre for conjugated movements of the 
eyes. Irritation of this centre causes the eyes to be directed toward the 
seat of irritation, while its paralysis is followed by their rotation in the 
opposite direction. In the angular gyrus is the centre for the levator 



Fig. 164. 




Diagram to illustrate the nervous apparatus of vision in man. (Sherrington.) 
L. Left eye. R. Right eye. o— x. Optic axis. Op. T. Right optic tract. Op. De. Optic 
decussation. L.F.L. and L.F.R. Right and left visual fields. GL. Lateral corpus gen- 
iculatum. Pv. Pulvinar. AQ. Anterior corpus quadrigeminum. op.rad. Optic radia- 
tion to R.Oc, the right occipital lobe. d. Direct tract to cortex, cc. Corpus callosum. 
l.v.d. Descending horn of lateral ventricle. Fr. Frontal cortex, fm.c. Path to nuclei ot 
third, fourth, and sixth nerves, p-b. Posterior longitudinal bundle. NC. Nucleus cau- 
datus. LN. Nucleus lenticularis. TH. Optic thalamus, cia. Front limb. cig. Knee, 
and cip, hind limb of internal capsule, p. Pineal gland. R Oc. Right occipital lobe. 



DISEASES OF THE BRAIN. 867 

muscle of the opposite eyelid, and its paralysis is followed by ptosis 
upon the opposite side. Lesions of the occipital cortex are associated 
with hemianopsia, which may be readily explained by reference to the 
accompanying diagram, since the fibres from the temporal half of the 
eye pass directly to the brain without crossing in the chiasm, together 
with the fibres from the nasal half of the other eye, which have crossed 
in the chiasm. (Fig. 164.) A lesion of their cortical centre is followed 
by paralysis of the temporal half of one retina and of the nasal half of 
the other, causing the abolition of the corresponding half of the visual 
field. Left-sided cortical lesions are thus associated with right-sided 
hemianopsia, and vice versa. In certain cases the visual defect is limited 
either to impressions of light, of color, or of spatial perception ; and in 
certain cases, though the power of vision is not destroyed, the patient 
can no longer comprehend the nature of the object which he sees. This 
condition is termed psychical blindness, or word-blindness when it is 
connected with the perception of written or printed words, and the 
comprehension of their significance. 

Local symptoms in diseases of the centrum ovale. The centrum 
ovale contains nerve fibres which connect different portions of the cor- 
tex of the same hemisphere with each other (associational system). 
Other nerve fibres pass through the corpus callosum, and connect cor- 
responding points in the cortex of the two hemispheres with each other 
(commissural system). There is no positive knowledge regarding the 
symptoms that are produced by diseases of these two systems of nerve 
fibres, but with regard to the nerve fibres which lie in the corona radiata 
it is known that their interruption occasions disturbance in the transmis- 
sion of impressions from without to the posterior cortical portion of the 
hemisphere, and of impulses from the cortical structure of the central 
convolutions to the pyramidal paths in the spinal cord. It consequently 
is impossible during life to differentiate between diseases of the cortical 
cells and interruptions in the course of the fibres that make up the 
corona radiata. 

Local symptoms produced by disease of the internal capsule. The 

motor fibres of the corona radiata converge within the middle third of 
the posterior limb of the internal capsule. (Fig. 165.) The path to 
the facial nerve occupies the anterior portion ; the path for the anterior 
extremity lies in the middle portion, and the path for the lower limb 
occupies the posterior portion of the middle third of the capsule. (Fig. 
166.) The sensory fibres which conduct impressions from the skin, 
muscles, and cerebral nerves form the posterior third of the posterior 
limb of the internal capsule. Diseases or injuries of the middle third 
of this posterior capsular limb are, therefore, followed by corresponding 
motor disturbances in the muscles of the face or extremities. The muscles 
of the forehead and the orbicularis palpebrarum muscle, which are con- 
nected with the upper branches of the facial nerve, escape paralysis, 
but it is not known whether this depends upon their being provided with 
a separate nerve centre and nerve fibres, or whether it is because the facial 
nerve nucleus is partly innervated from the opposite side of the brain. 



868 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

The last hypothesis seems to be the more probable. Diseases of the 
motor portion of the interior capsule are seldom limited to that region, 
since the limitation of cerebral diseases is not conditioned by systema- 
tized arrangements of nervous elements, but is dependent upon the dis- 
tribution of the bloodvessels. The internal capsule and the corpus 

Fig. 165. 




Outline of a transverse dorso- ventral section of the right half of the brain, showing the 
course of the fibres of the corona radiata converging from the cortex to CI, the internal 
capsule. Natural size. (Sherrington.) 

striatum are supplied by the same bloodvessels and participate in the 
same disease-processes. Paralytic symptoms which are associated with 
disease of the corpus striatum are therefore not dependent upon that 
particular locality, but upon the pressure or actual disease that has been 
sustained by the adjacent motor fibres within the internal capsule. 

Diseases of the posterior third of the posterior limb of the internal 
capsule involve sensory nerve fibres, and occasion cerebral hemi-ancesthe- 
sia. The entire opposite side of the body, from the crown of the head 



DISEASES OF THE BRAIX. 



869 



to the sole of the foot, is rendered anaesthetic. Vasomotor changes, viz., 
increase of temperature, vascularity of the skin, and perspiration, are 
frequently connected with such diseases. 



Fig. 166. 




Outline of horizontal section of brain, to show the internal capsule. Natural size. 

(Foster.) 
OT. Optic thalamus. NL. Nucleus lenticularis. Nc. Nucleus caudatus. G. Knee of 
the internal capsule. From Eye to Dig, marks the position of the pyramidal tract as a 
whole. Eye, fibres for movements of the eye; Hd, of the head; Tg, of the tongue; mth, 
of the mouth; Shi, of the shoulder; Elb, of the elbow; Dig, of the hand; Abd, of the 
abdomen; Hip, of the hip; Kn, of the knee: Dig, of the foot. S. Temporo-occipital 
tract, oc, fibres of the occipital lobe, op, optic radiation. 

Local symptoms of disease in the basal cerebral ganglia. Diseases 
of the nucleus caudatus and of the lenticular nucleus produce no per- 
manent motor disorder. Such transient paralysis as may be observed 
is dependent upon pressure exerted upon the neighboring internal 
capsule. 



870 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

Local symptoms in disease of the crura cerebri. L '■> the 

crura cerebri are recognized by the occurrence of alternate hemiplegia 
involving the oculo-motor nerve. The cerebral motor nerves and the 
extremities are paralyzed upon the side opposite to the lesion, while the 
oculo-motor nerve is paralyzed upon the same side with the lesion. Only 
when the greater portion of the pyramidal tract fails to pass over 
to the opposite side at the point of pyramidal decussation, does the 
paralysis of the extremities occur upon the same side with the lesion. 
If the lesion be placed high up in the cerebral portion of the crus, the 
oculo-motor nerve upon the opposite side is paralyzed, and the symptoms 
partake of the characters of an ordinary crossed hemiplegia such as 
follows lesions of the internal capsule. Minute lesions that do not in- 
volve the pyramidal path in the middle third of the crus produce no 
symptoms that can be recognized during life. 

The tegmentum contains sensory fibres which pass upward into the 
sensory portion of the internal capsule, consequently their interruption 
produces sensory disturbances similar to those which follow injury of 
the capsule itself. 

Local symptoms in disease of the pons Varolii. Circumscribed 

diseases, like the tubercular formations, may exist in the pons Varolii 
without producing any local symptoms : but when the motor path is in- 
jured a form of hemiplegia is produced that is pathognomonic for dis- 
eases of the pons. A crossed paralysis (hemiplegia aiternans) occurs, 
and is characterized by paralysis of the facial nerve upon the side of the 
lesion, while the extremities are paralyzed upon the other side. The 
facial paralysis resembles peripheral facial paralysis in the fact that it 
involves all the branches of the nerve, and that the muscles exhibit the 
reaction of degeneration which is observed in cases of peripheral paral- 
ysis. This result is witnessed when the lesion is situated in the medul- 
lary portion of the pons, below the decussation of the fibres to the facial 
nerve nucleus, but above the decussation of the pyramidal paths. 
When the lesion occurs in the cerebral half of the pons, above the 
decussation of the fibres to the facial nerve, complete hemiplegia occurs, 
involving all below the oculo-motor nerve, like that which is observed 
when the paralysis is of cerebral origin. 

Ziesions in the pons are sometimes followed by disturbance of the 
nerves that spring directly from its neighborhood, or of the bulbar 
nerves immediately below, as a consequence either of direct paralysis, 
or of indirect influences exerted from a distance. Conjugated deviation 
of the cues and head are sometimes observed, but this symptom differs 
from conjugated deviation of cerebral origin in the fact that the head 
and eves are turned away from the side of the lesion. 

Diseases of the pons are frequently accompanied by great elevation of 
the temperature; and if the lateral third of the pons be involved, a 
thesia is sometimes observed upon the same side of the body with the 
motor paralysis. The symptoms that follow diseases of the pons ob- 
viously vary according to the extent and situation of the disease, con- 
sequently a great variety of permutations becomes possible, requiring 
great anatomical facility for their explanation. 



DISEASES OF THE BRAIN. 871 

Diseases of the thalamus opticus produce no motor symptoms. 
Diseases in its posterior third occasion lateral hemianopsia, like dis- 
eases of the occipital cortex. Other disturbances of motion and sensa- 
tion associated with thalamar lesions are occasioned by pressure upon 
the neighboring limb of the internal capsule. 

Diseases of the external capsule and claustrum produce no recog- 
nizable symptoms. The same thing is true of diseases of the Amnion's 
horn. 

Diseases of the corpora quadrigemina are associated with disturb- 
ances of vision, paralysis of the ocular muscles, and defective equili- 
bration of the body. Loss of sight, with pupillary paralysis and nega- 
tive ophthalmoscopic appearances, are associated with the anterior pair 
of the corpora. Injuries of the postenor pair produce paralysis in the 
branches of the oculo-motor and trochlear nerves, and are accompanied, 
in certain cases, by the symptoms of cerebellar ataxia. 

Diseases of the cerebellum are not attended by characteristic 
symptoms. The hemispheres may be involved without any consequent 
symptoms, and the association of a staggering gait and vertigo with 
lesions of the vermiform process is still disputed. 

Diseases of the crura cerebelli produce no symptoms, except when 
the crus cerebelli ad pontem is merely irritated. Certain compulsory 
movements of a rotary character, twisting around the axis of the body, 
etc., are then observed. 

Local symptoms in diseases at the base of the brain are indicated 
chiefly by paralysis of the cerebral nerves through compression. When 
the posterior cerebral fossa is invaded, the symptoms may resemble the 
course of progressive bulbar paralysis. 

Aphasia — Agraphia — Alexia — Amimia — Apraxia — Asymbolia. 

Certain local diseases of the cerebral cortex and corona radiata pro- 
duce disturbances in that power of expression by which the individual is 
enabled to communicate his thoughts and feelings to the external 
world. When this disability involves the power of speech, it is termed 
aphasia ; when the power of reading is lost, alexia ; when the power of 
communicating thought by gestures is destroyed, it is termed amimia ; 
when the comprehension of the nature and uses of objects disappears, 
the condition is termed apraxia. By the term asymbolia is signified 
the loss of all power of communication with the external world. 

Simple aphasia consists in the loss of the power of vocal utterance. 
This may depend either upon injury of the voluntary path between 
the cerebral cortex and the vocal organs (motor or ataxic aphasia, sub- 
cortical motor aphasia), or it may be the result of an interruption 
in the sensory path between the recipient organs of sense (eye, ear, etc.), 
and the cortical centres of perception and comprehension (sensory 



^72 DISEASES OF BRAIX AND CEREBRAL MEMBRANES. 

aphasia). The mechanism of aphasia may be conveniently studied in 
connection with auditory lesions, involving the cortical paths and 
centres between the nucleus of the a nerve and the nuclei of the 

nerves that control the muscles of articulation. This may be 
rendered intelligible by reference to the accompanying schemati: 
resentation. Fig. 167. The fibres in the posterior portion of the 




_ rram illustrative of the mechanism of auditory and visual perception, conception, 
and vocal or graphic utterance. (After Eichho ? s - . 

:rtical auditory centre. V. Cortical visual cenrrr entre for the con- 

ception of ideas. S. Cortical centre for coordination of the muscles of speech. G 
tical centre for coordination of the muscles used in writing. A P. &ab-eortical sensory 
path for auditory impressions. V P. Sub-cortical sensory path for visual impressions. 
Irans-cortical sensory paths. — Vfi 3G 3 8 Trans- 

cortical motor paths. S P and G P. Sub- cortical motor paths. 

internal capsule and corona radiata that lie between the an r.erve 

nucleus and the cortical centre for auditory pereepti -titute the 

sub-cortical sensory path. The pen centre is located in the first 

temporal convolution. The cortical centre for vocal utterance occupies 
the base of the third frontal convolution. The association fibres in 
the neighborhood of the island of Reil. between the third frontal 
volution and the first temporal convolution, form the path of communi- 
itween the au jntre and the centre for vocal utterance. 

Perception takes place in the first centre, voluntary impulse to utter- 
ance > 1 in the other. The centre for comprehension of pei 
tion is connected with the perceptive centres by the fibres of the trans- 
cdrtic a a ry path, and with the vocal centre by the fibres of the 
trans-cortical tth. If now the sub-cortical sensory path be 
interrupted, auditory perception cannot occur (^sub-cortical se 
aphasia i : and a similar result foil iction of the auditory per- 
ceptive centre itself (cortical sensory aphasia). In this way w 



DISEASES OF THE BRAIN. 873 

deafness may be produced. The patient hears, so far as the ear is con- 
cerned, but he cannot perceive or comprehend the meaning of the 
sounds that are received by the brain, though he can still think, and 
utter his thoughts through the intervention of the cortical centre for 
comprehension and the trans-cortical motor path that connects it with 
the cortical vocal centre. 

If now the path between the auditory centre and the vocal centre be 
interrupted, the patient can hear and comprehend what is addressed to 
him, and can voluntarily utter his own thoughts ; but he cannot repeat 
the words that he hears. 

If the trans-cortical sensory fibres between the auditory centre and 
the centre for comprehension be interrupted, the patient can hear words, 
and can repeat them ; but he cannot comprehend their meaning, though 
able voluntarily to utter his own thoughts (trans-cortical sensory apha- 
sia). The utterances of such a patient are liable to some degree of 
confusion, since his memory of words is no longer controlled by intelli- 
gible audition. 

Destruction of the centre for comprehension is attended with loss of 
the power of comprehending the nature and uses of the objects of per- 
ception (apraxia). 

Interruption of the trans-cortical motor path between the centre of 
comprehension and the vocal centre is attended by perfect auditory 
perception and comprehension, also by the power of repeating words 
that are heard, and of performing such acts as are audibly commanded ; 
but he is unable to express his thoughts by vocal utterance. Such 
cases constitute what is frequently termed amnesic aphasia. Since the 
difficulty of voluntary utterance is associated with forgetfulness of the 
necessary words, the more intimate the relation between word and idea 
the more easily is its memory lost ; while ideas that are connected with 
actions rather than with words are longer retained. Hence the ready 
forgetfulness of proper names and substantives, while verbs, the words 
of action, are longer retained in the memory. This variety of aphasia 
is termed trans-cortical motor aphasia. 

If now the vocal centre be injured (motor aphasia), or if the fibres 
between that centre and the nuclei of the nerves that arouse the mus- 
cles of articulation be interrupted (sub-cortical motor aphasia), sensation, 
perception, and comprehension of audible sounds may be complete, but 
the utterance of voluntary thoughts and the repetition of audible words 
will be rendered impossible. If the sub-cortical paths between the 
volitional centres and the muscles of the extremities remain intact, it 
may be still possible for the patient to express his thoughts in writing 
or by gestures. 

Similar disturbances of expression must obviously accompany corre- 
sponding lesions of the sub-cortical paths and cortical centres that are 
concerned in the perception and comprehension of visual impressions, 
or any other impressions of sense and their cerebral paths of commu- 
nication with the vocal centres, or with other centres for the coordina- 
tion and communication of central impulses to the external world. 

It is an interesting fact that aphasic symptoms are usually dependent 
upon lesions involving the left hemisphere of the brain. This is appar- 



874 DISEASES OF BRAIN AXD CEREBRAL MEMBRANES. 

ently due to the greater development of that hemisphere in consequence 
of its more perfect supply of blood during the period of development, 
and of other causes that have given it the preference as the organ of 
expression. When aphasia occurs in connection with lesions of the 
right hemisphere of the brain, it is usually observed in left-handed per- 
sons. 

The seat of those lesions by which the different forms of aphasia are 
produced is. in the great majority of cases, within the territory that 
receives its vascular supply from the branches of the Sylvian artery. 
Rupture or obstruction of those vessels may produce aphasia as a con- 
sequence of compression or softening of the cortical tissues : but apha- 
sia may also be the result of direct injuries of the cortical substance. 
such as are observed after fractures of the skull with depression of the 
interior table of the bone, producing compression and paralysis at the foot 
of the third frontal convolution. Similar consequences may be devel- 
oped by tumors and by the products of inflammation, when they com- 
press the centres and paths of voluntary utterance. The same thing 
may happen as a consequence of microscopical changes in the cortex, 
by reason of which the cortical ganglionic cells undergo atrophy and 
disappear. It occasionally happens that transient aphasia may be 
witnessed as a consequence of modification of the circulation in hysteria, 
chorea, catalepsy, and after epileptic seizures, or by reason of irritation 
that has its origin in the alimentary canal under the influence of para- 
sites or obstinate constipation of the bowels. In similar cases the 
power of speech is sometimes suddenly restored through excessive 
emotion or intellectual excitement. 



CHAPTER III. 

DISEASES OF THE CEREBRUM. 

Cerebral Anaemia — Anaemia Cerebri. 

Pathological Anatomy. Cerebral anaemia is characterized by a 
deficiency of blood in the vessels of the brain and of the pia mater. 
There is universal pallor of the cerebral substance, together with ab- 
normal reduction of its fluid constituents, when anaemia is caused by 
hemorrhage or other conditions that greatly diminish the liquids of the 
body ; but in cases of dropsical anaemia the cerebral tissue may be 
unusually soft and soaked with fluid. 

Etiology. The causes of cerebral anosmia are frequently dependent 
upon excessive hemorrhage, or upon the sudden abstraction of fluids from 
any of the great cavities of the body. It may occur as a consequence 
of shock, by which the abdominal vessels are excessively dilated and 
compelled to detain the greater portion of the blood from the rest of the 
body. 



DISEASES OF THE CEREBRUM. 875 

Cerebral anaemia is frequently observed among young children, as a 
consequence of profuse and exhausting diarrhoea, and it often results 
from other diseases that are attended by great impoverishment of the 
blood. When the number of red blood-corpuscles is considerably dimin- 
ished, the circulation of such blood is followed by the symptoms of 
anaemia in the brain and elsewhere. 

Cerebral anaemia may result from embolism or thrombosis in the cere- 
bral vessels, or from their compression by tumors, hemorrhages, or 
exudations within the cavity of the cranium. Arterial and venous dis- 
eases and cardiac debility may interfere with the proper supply of blood 
to the brain. 

Vasomotor spasm, under the influence of violent emotion, or excited 
by certain poisons, frequently results in temporary cerebral anaemia. 

Symptoms. One of the most common and perfect illustrations of the 
consequences of cerebral ancemia is furnished by the occurrence of 
syncope, or fainting. This condition is brought about by a sudden 
spasm of the cerebral vessels, shutting off the supply of blood, for the 
time being, from the cortical tissues. The vascular spasm is usually 
excited by violent emotion ; the patient experiences a sensation of con- 
striction and distress in the region of the heart, sometimes accompanied 
by palpitation ; there is an inclination to yawn, a sensation of cold creeps 
over the skin, and the countenance becomes pale, the ears ring, sounds 
grow faint, sight fails, the constricted pupils become dilated, everything 
is in a whirl, and perhaps nausea is experienced. The muscles of the 
face and of the fingers begin to twitch, consciousness is lost, and the 
patient falls as if lifeless to the floor. Death sometimes follows the 
appearance of these symptoms, but generally after the lapse of a few 
seconds the patient heaves a deep sigh, and speedily recovers. 

Severe epileptiform convulsions are sometimes associated with these 
symptoms when accompanied by excessive loss of blood. Young chil- 
dren frequently display similar phenomena in lesser degree during a 
considerable period of time as a consequence of exhausting diarrhoea. 
In such cases the child lies cool and pale, with sunken fontanelles and 
wasted visage, while delirium and slight spasmodic movements manifest 
the existence of cerebral irritation. As the disease progresses, irritation 
gives way to utter exhaustion. Coma, asphyxia, and death conclude 
the scene, thus furnishing an excellent illustration of the manner in 
which paralysis and irritation may be associated, or succeed one another, 
as consequences of cerebral anaemia. 

Similar consequences are not unfrequently observed among grown 
people in the course of exhausting diseases. Violent delirium, some- 
times attaining to maniacal proportions, may be suddenly developed, 
and after raging for a time may be merged in somnolence and coma. 

Besides the symptoms already mentioned, headache, dizziness, paraes- 
thetic disturbances of ordinary sensation, and perversions of the special 
senses are not uncommon. In many cases the symptoms are greatly 
aggravated by sudden assumption of the erect position, leading occa- 
sionally to fatal syncope. 

Treatment. So far as possible the causes of anaemia must be 
ascertained and removed. Correct hygiene, abundant and wholesome 



876 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

diet, and a health} 7 habitation in a salubrious locality, must be secured. 
A tendency to syncope may be obviated by placing the patient upon a 
bed with the feet elevated above the level of the head. Ammonia, 
mustard, and other external stimulants may be employed. Wine, 
whiskey, coffee, tea, beef-tea, and valerianate of ammonia may be ad- 
ministered internally, while ether may be injected hypodermically, in 
ten- drop doses every five or ten minutes, or a syringeful of a ten per 
cent, solution of camphor in oil of almonds may be employed in the same 
way. Cerebral excitement and loss of sleep require the administration 
of opiates, paraldehyde (one or two drachms at bedtime), or chloral 
hydrate (half a drachm at a time). Chronic cases are sometimes bene- 
fited by the use of electricity. 

Cerebral Hyperaemia — Hyperemia Cerebri. 

Hypercemia may be either acute or chronic, active or passive. Active 
hypercemia is often dependent upon excessive energy of the heart when 
that organ has undergone concentric hypertrophy. It may also occur 
when a considerable portion of the arterial circulation is cut off by the 
compression of tumors or other causes of arterial constriction, so that 
the brain is subjected to an unusual afflux of blood. This may also re- 
sult from the suppression of customary hemorrhagic discharges. It is 
sometimes produced by paralysis of the vasomotor nerves, such as oc- 
curs during violent mental excitement, or as a consequence of the 
excessive use of alcohol. It sometimes is associated with inflammatory 
diseases about the head and in the neighborhood of the brain. 

Passive cerebral hyperemia may result from thrombosis of the cere- 
bral sinuses, or from obstruction of the jugular veins, or as a conse- 
quence of cardiac and respiratory diseases that interfere with the ready 
return of blood from the head. 

Pathological Anatomy. Cerebral hyperemia occasions extensive 
dilatation and distention of the cerebral bloodvessels. The cerebral 
cortex appears unusually dark in color, and the white substance of the 
centrum ovale is in like manner slightly discolored and marked by the 
appearance of droplets of blood in unusual number at the orifices of the 
incised bloodvessels. Microscopical examination reveals a distended 
condition of the lymphatic sheaths of the bloodvessels, and they fre- 
quently contain red blood-corpuscles that have escaped in considerable 
number from the vessels themselves. The ganglionic cells are fre- 
quently loaded with yellow pigment, and the neuroglia is somewhat 
increased in quantity. In chronic cases the cerebral tissues undergo a 
certain amount of atrophy. 

Symptoms and Diagnosis. The symptoms of cerebral hypercemia 
agree, in many respects, with those of cerebral anaemia. In both cases 
a stage of irritation is liable to be followed by a stage of paralysis. 
Irritative symptoms usually depend upon active arterial hyperaemia, 
which occasions compression, and suppression of function, in the cere- 
bral tissues. 

Irritation of the brain is indicated by psychical disturbances. The 
patient becomes excitable and incapable of clear and steady thought. 



DISEASES OF THE CEREBRUM. 877 

Not unfrequently delirium occurs, and it may reach the height of 
maniacal fury. Sleep is disturbed by agitated and exhausting dreams. 
Dizziness, headache, sensations of heat, confusion of ideas, and loss of 
consciousness are not uncommon. Sometimes apoplectiform attacks are 
experienced. Common sensation undergoes various paresthetic modi- 
fications, e. g., numbness, formication, sensations of heat ; and the spe- 
cial senses are more or less involved, so that there is complaint of seeing 
sparks, of dimness of vision, roaring in the ears, difficulty of hearing, 
etc. Sometimes light and sound become intolerable by reason of the 
exalted condition of the sensory organs. 

In certain cases convulsive symptoms are manifested, rendering it 
difficult to distinguish the case from an attack of genuine epilepsy. 
Sometimes transient paralysis is observed. 

Cerebral hypercemia may exist as a constant condition, or it may 
occur paroxysmally for a comparatively brief period of time. During 
an attack the face is highly colored and somewhat swelled. If hyper- 
emia is of a passive character, the skin appears cyanosed, the heart 
beats rapidly, with a full, hard pulse in congestive cases, but it is soft 
and often almost imperceptible in the passive form of the disease. 
Respiration is frequently irregular, and becomes stertorous in cases of 
coma or of apoplectiform seizure. Sometimes the temperature is 
slightly elevated. Vomiting may occur. 

Prognosis and Treatment. The prognosis depends upon the 
nature of the cause that operates to produce cerebral hyperemia. It 
is unfavorable in epileptiform or apoplectiform varieties of the disease. 
The treatment must also depend upon the nature of each individual case. 
Cardiac weakness and passive hyperemia require the administration of 
digitalis ; while active hyperemia must be relieved by change in the 
diet and habits of life, together with the administration of cathartics 
and laxative mineral waters. Severe paroxysms of hyperemia in 
plethoric subjects may require the abstraction of blood. Ice should be 
applied to the head, and an active cathartic should be administered. 
The feet may be placed in hot water, and a low diet should be ordered. 
Sleeplessness must not be treated by the administration of opiates or 
chloral hydrate. Large doses of bromide of potassium or of sulphonal 
are followed by a more favorable result. Chronic cerebral hyperemia 
is sometimes benefited by the use of electricity about the head and 
neck. 

Sunstroke — Thermic Fever — Insolatio. 

Exposure to excessive heat is sometimes followed by severe symptoms 
of general prostration, cardiac failure, cerebral hyperemia, and death. 
But if recovery takes place, convalescence is tedious and imperfectly 
terminated, sometimes resulting in a chronic condition of cerebral ex- 
haustion or chronic inflammation. 

Etiology. Sunstroke usually follows exposure to the rays of the 
sun during the heat of summer, or in tropioal climates. Artificial heat, 
especially when combined with ill-ventilation and stagnation of a humid 
atmosphere, may also produce the disease. It is thus witnessed among 



878 DISEASES OF BRAIX AND CEREBRAL MEMBRANES. 

coal-heavers and firemen on the steamships that traverse the lied Sea 
and other torrid regions. It is sometimes also experienced during the 
night when the weather is sultry and the air is stifling. A warm and 
reeking atmosphere is much more prejudicial than dry heat. Cases of 
sunstroke sometimes occur when the temperature of the air scarcely 
exceeds 80° F., because when laden with moisture it cannot evaporate 
perspiration from the body, and heat consequently accumulates in the tis- 
sues. But when the air is dry, a high temperature actually refrigerates 
the body by the rapid evaporation of perspiration which it produces. 

The effects of a high temperature are rarely prejudicial to a person in 
complete health. It is when the nervous system has been exhausted by 
previous illness, fatigue, or debauchery, that the individual succumbs to 
insolation. The controlling influence of the nervous system over 
the production, distribution, and liberation of heat, is under such cir- 
cumstances diminished, and the tissues are therefore unable to adjust 
themselves to an excessive temperature. Imperfect elimination through 
the kidneys, intestines, and skin adds to the disorder of the system ; 
and by the accumulation of poisonous excreta subjects the nervous 
centres to influences of a toxic character, by which their regulative 
power over the functions of circulation and nutrition is inhibited. 
These morbid conditions are greatly aggravated by chronic alcoholism, 
and by the excessive use of cold water when overheated. 

Symptoms. Mere exposure to the direct rays of the sun on the part 
of a healthy person produces nothing worse than an erythema of the 
skin upon the parts that are exposed. A thin and delicate cuticle is 
not unfrequently blistered under such circumstances ; but, after a time, 
through repeated exposure, it becomes thickened, hardened, pigmented, 
and correspondingly insensitive to the effects of solar heat. When the 
inhabitants of the temperate zone remove to tropical climates, they 
frequently experience a brief course of fever, lasting for a week or ten 
days, and terminating in recovery. This thermal fever is usually re- 
ferred to the direct effects of heat, but it is probably caused in great 
measure by a disturbance of the thermic centres in the brain, under the 
influence of a diet and habits of life that have been only imperfectly 
adjusted to the change of climate. 

A sunstroke is usually preceded for several days, by symptoms of ill 
health. The bowels are frequently constipated ; there is loss of appe- 
tite, and indigestion is developed ; the urine becomes scanty, though a 
frequent desire to urinate is experienced ; perspiration is more or less 
suppressed ; there is a feeling of general exhaustion, with disinclination 
to active exercise ; dizziness, headache, loss of memory, vertigo, and a 
disposition to sleep are often observed. 

The attack is manifested under two principal forms. In the first the 
symptoms of cardiac exhaustion are most conspicuous. The patient 
falls to the ground, complaining of pain in the precordial region. 
Respiration is somewhat difficult ; the face is pale, and symptoms of 
intense prostration are manifested. Under favorable circumstances, 
however, recovery may take place in the course of two or three days, 
though in many instances the attack is succeeded by persistent debility 
and incapacity for active exertion. Sometimes it is impossible to en- 



DISEASES OF THE CEREBRUM. 879 

dure subsequent exposure to a high temperature. Obstinate headaches 
are often experienced, and the patient exhibits great deterioration 
in bodily health, intellectual vigor, and psychical character. 

A severe attack is ushered in with similar promonitory symptoms. 
There is intense headache ; the face is sometimes swelled ; the pupils 
are contracted ; respiration is irregular and labored ; the heart beats 
rapidly, irregularly, and feebly ; nausea and vomiting are sometimes 
experienced ; the skin is hot and dry, or sometimes covered with per- 
spiration ; the temperature rises to 106° or 110° F. ; convulsions are 
occasionally witnessed, and the patient passes rapidly into a condition 
of profound coma. The pupils then dilate ; respiration becomes ster- 
torous ; mucous rales develop in the trachea ; foam appears upon the 
lips ; the skin is cyanosed : and death speedily follows. 

After a mild attack recovery is completely established in the course 
of two or three days ; but severe forms of the disease either terminate 
fatally in the course of a few hours, or in recovery after a long and 
tedious illness, characterized by a febrile movement and symptoms of 
subacute meningitis. Contractures and muscular atrophy are some- 
times developed as sequels of the disease. In malarious countries and 
during the prevalence of yellow fever, the occurrence of sunstroke is 
often followed by pernicious fever or by yellow fever itself. 

Pathological Anatomy. The temperature of the body remains for 
many hours after death elevated above the normal standard. Rigor 
mortis is rapidly developed. Livid spots and ecchymoses are frequently 
observed upon the skin, and a sanguinolent fluid trickles from the mouth 
and nostrils of the cadaver. The left side of the heart is empty, but 
the right side and the large veins are distended with black, fluid blood. 
The cerebral sinuses and veins are engorged with blood, and a consider- 
able amount of serum occupies the cavities of the membranes and the 
ventricles. The cortex of the brain is congested, and sometimes punc- 
tate hemorrhages exist in the cerebral substance. The lungs are exces- 
sively congested; the bronchi are filled with sanguinolent froth; and 
not unfrequently the pleural cavities contain a large quantity of blood- 
stained fluid. The liver and spleen are always congested. The gastro- 
intestinal mucous membrane exhibits a similar tendency ; and the kid- 
neys are usually overloaded with blood. 

Diagnosis. The circumstances under which the attack is developed, 
and the high temperature of the body, usually exceeding that of any 
other acute disease, render the diagnosis easy. 

Sunstroke must be differentiated from cerebral hemorrhage, from 
cerebro-spinal meningitis, and from the cerebral form of pernicious fever. 

Cerebral hemorrhage is accompanied by a violent rending pain in. the 
head. There is sometimes sufficient preservation of consciousness to 
enable the patient to call for assistance before falling to the ground. 
There is usually the development of hemiplegia, and if paralysis be 
total, it is more pronounced upon one side than upon the other, while in 
the case of insolation there is complete paralysis and insensibility. The 
temperature is very slightly elevated after cerebral hemorrhage, and the 
pulse and respiration do not exhibit that excessive disturbance which 
characterizes a sunstroke. 



880 DISEASES OF BRAIX AND CEREBRAL MEMBRANES. 

Cerebrospinal meningitis is characterized by intense headache, which 
involves the back of the neck and the spinal column. There are ver- 
tigo, nausea, and vomiting. Convulsive movements agitate the limbs ; 
the head is drawn backward ; there is no paralysis. The temperature 
is but moderately increased, and the pulse seldom rises above 100 or 
120 beats. 

Pernicious malarial fever usually occurs during the course of an ordi- 
nary malarial fever. The temperature does not rise above 104° or 106° 
F., and rapidly subsides with the decline of the paroxysm. 

Prognosis. In severe cases sunstroke usually proves fatal. The 
average mortality is probably about 40 per cent. 

Treatment. The clothing of persons who are exposed to a high 
temperature should be light and loosely girded, so as to favor the rapid 
evaporation of perspiration. An abundance of cool water should be 
furnished to compensate for copious evacuation through the skin. Total 
abstinence from intoxicating drinks, and strict observance of the ordi- 
nary rules of hygiene should be enjoined. Constipation must be pre- 
vented, and the functions of the alimentary canal must be maintained 
in a state of normal health. Thus guarded, it becomes possible to 
endure the most intense solar heat without serious injury. 

But when a sunstroke has been experienced the patient should be 
placed in a cool and shaded place, and all unnecessary clothing should 
be removed. Cold water should be poured freely over the head, neck, 
and entire body, so as to reduce the temperature as rapidly as possible. 
In minor forms of the attack, coffee with a little brandy, aromatic 
spirits of ammonia, and other gentle stimulants, may be administered. 
As soon as recovery occurs, a cathartic dose of calomel may be admin- 
istered and followed by tonic doses of quinine. In severe forms of the 
disease characterized by coma, ice should be freely used about the head 
and entire body. A large injection of ice-water may be thrown into 
the bowels in order to cool the interior of the abdomen. Convulsions 
should be relieved by the hypodermic injection of one-tenth of a grain of 
apomorphia. When the symptoms exhibit a tendency to profound 
asphyxia, indicated by cyanosis of the skin and distention of the veins, 
copious bleeding from the arm will sometimes revive the circulation and 
rescue the patient. During the period of restoration, when the symp- 
toms of thermic fever are developed, phenacetine may be given in doses 
of five or ten grains every two hours until the temperature is reduced. 
Convalescence should be aided in accordance with general principles. 

Cerebral (Edema — (Edema Cerebri. 

Cerebral a j dema occurs in connection with those diseases of the circu- 
latory apparatus, or of the blood that lead to dropsical effusions in other 
parts of the body. It occasions symptoms of intra-cranial pressure ac- 
companied by interference with, and final paralysis of the cerebral 
functions (serous apoplexy). 

Cerebral Hemorrhage — Encephalorrhagia. 

Cerebral hemorrhage is more common among men than among 
women. It is a disease of old age, and occurs with increasing frequency 



DISEASES OF THE CEREBRUM. 881 

as one recedes beyond the fortieth year. Hereditary causes are proba- 
bly not without influence, since the disease is often observed among 
relatives in the same line of family descent. 

Cerebral hemorrhage in the vast majority of cases is caused by changes 
in the walls of the cerebral bloodvessels. These morbid processes are 
usually dependent upon old age, but they may exist as a consequence of 
chronic renal disease, alcoholism, syphilis, lead poisoning, and valvular 
disease of the heart. Under such circumstances, vascular rupture may 
occur through the influence of any accidental increase in the pressure of 
the blood ; but frequently it happens during sleep, without any apparent 
exciting cause. 

Pathological Anatomy. Superficial hemorrhage upon the external 
surface of the cerebrum causes distention of the cerebral membranes, 
and the bloody extravasation sometimes finds its way into the spinal 
canal. The convolutions of the brain are sometimes compressed and 
rendered anaemic, as a consequence of the exclusion of blood from their 
vessels through pressure exerted by the hemorrhagic clot. The quan- 
tity of blood that is effused exhibits great variations. In the majority of 
cases hemorrhage takes place upon one side only of the brain ; but 
successive hemorrhages may occur, involving now one hemisphere and 
then the other. In the pons Varolii hemorrhages near the median line 
may involve both sides at once. 

When first extravasated, the seat of hemorrhage is occupied by a 
mass of red, coagulated blood, mixed with fragments of cerebral tissue. 
In certain cases there is nothing more than punctate hemorrhage from 
minute capillary vessels, but this may in time occasion a considerable 
accumulation of blood. Gradually the blood corpuscles are broken up, 
and by the separation of their pigment a dark-colored mass is formed 
that contracts, and floats in a serous fluid that is retained by a capsular 
wall of thickened connective tissue, constituting an apoplectic cyst. In 
many cases the contents of such' cysts contain minute oil globules and 
fatty cells, together with crystallized pigment from the blood corpuscles. 
Gradually contraction takes place, and a pigmented mass of cicatricial 
tissue occupies the seat of the original hemorrhage. 

Examination of the bloodvessels, in cases of cerebral hemorrhage, in- 
dicates the existence of numerous minute miliary aneurisms that are 
usually developed at the bifurcation of the arterial twigs. The process 
consists in the development of inflammatory or sclerotic changes in the 
walls of the arteries, by which their muscular coat is destroyed so that 
the endothelial lining is pushed outward and blends with the lymph- 
vascular sheath, to form the aneurismal wall. These minute aneurisms 
are most numerous in the thalamus opticus and corpus striatum ; then, 
in order of frequency, in the cerebral cortex, in the pons, in the medulla 
oblongata, and in the gray matter of the cerebellum. 

Symptoms. Prodromal symptoms consist, for the most part, of 
pressure of blood into the head, dizziness, dimness of vision, black 
specks before the eyes, roaring in the ears, and partial loss of hearing, 
general discomfort, and sense of constriction. There is evident loss of 
memory, and of the power of mental concentration and effort, dis- 
turbance of the emotional nature, distressing dreams, and restless sleep. 

56 



882 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

Sometimes there are tingling sensations and feelings of numbness and 
weakness in the extremities. These symptoms may be developed 
rapidly, or they may persist for a long time before the culmination of 
an attack. 

The apoplectic seizure usually develops itself quite rapidly. In certain 
cases the patient falls insensible to the floor, but in other cases the power 
of motion disappears gradually, and consciousness vanishes at a later 
period, or not at all. In the severest forms of the disease death may 
occur almost immediately, but in milder cases, though comatose, the 
patient will respond to a pinch or a prick by opening the eyes, moving 
the limbs, and uttering a groan. In severe cases accompanied by com- 
plete coma it is often impossible to determine the existence of hemiplegia, 
since all the extremities appear equally relaxed, but in less completely 
developed attacks unilateral paralysis may be usually demonstrated 
without difficulty. The observer should be cautious, in severe cases, 
lest he mistake apoplexy for alcoholic intoxication or poisoning with 
opium. In the first case, the odor of alcohol does not always exclude 
apoplexy, since intoxicated persons may also surfer with cerebral hemor- 
rhage. Opium poisoning is accompanied by contraction of the pupils, 
and their dilatation during coma should lead to the suspicion of cerebral 
hemorrhage. 

When hemiplegic symptoms are present, the paralyzed side of the face 
moves only during the acts of respiration. The ala nasi and the paral- 
yzed lips and cheek are puffed out and passively drawn in with each 
expiration and inspiration. The powerless limbs fall lifeless by the side 
of the patient, and offer no resistance to passive movements. The 
cutaneous reflexes disappear upon the affected side ; and when hemor- 
rhage involves the motor zone of the cerebral cortex, or the pons 
Varolii, or when the walls of the lateral ventricles of the brain have 
been broken down by extensive clots, unilateral spasms and contractures, 
or epileptiform convulsions are frequently observed. Sometimes there 
is conjugated deviation of the head and eyes toward the seat of hemor- 
rhage, when it involves the cortical portion of the parietal convolutions 
(gyrus supra-marginalis). The circulation exhibits variable conditions. 
In certain cases the pulse is full, hard, and slow ; in others it is rapid, 
soft, and weak. The face may be either flushed, and damp with per- 
spiration, or pale and cool. Respiration may be slow, stertorous, or 
deep and irregular. During the stage of irritation the pupils are 
contracted. As this stage merges into a condition of great cerebral 
pressure and profound paralysis, the pupils become unequal, and finally 
they are widely dilated. Vomiting is not an uncommon event. The 
temperature falls for a short time, and if a fatal termination be imminent 
it rises to an extraordinary degree, except in those fulminant cases when 
death occurs almost immediately. 

The return of consciousness after an apoplectic seizure is sometimes 
quite sudden, especially after copious bleeding ; but usually it occurs 
gradually, and may sometimes require many days for its completion. 
In fatal cases coma deepens, pulse and breathing fail, the skin becomes 
cyanosed ; noisy, tracheal riiles impede respiration, and death occurs in 
a condition of complete collapse. Apparent recovery is not unfre- 



DISEASES OF THE CEREBRUM. 883 

quently followed by successive relapses until at last a fatal termination 
is reached. 

The period of reaction after an apoplectic attack is usually character- 
ized by delirium, fever, with considerable elevation of temperature, and 
more or less pain, accompanied by slight spasms and contractures in the 
paralyzed limbs. These spasms are the consequence of irritative inflam- 
matory processes in the tissues around the seat of hemorrhage. 

The permanent results of cerebral hemorrhage are developed in cases 
of recovery during the period of convalescence. They are character- 
ized by symptoms of a local character, which vary according to the seat 
and extent of the cerebral lesion. Hemorrhage into the internal capsule 
and neighboring ganglia is the favorite seat of cerebral hemorrhage that 
produces motor hemiplegia. Sensory disturbances frequently exist for 
a short time, but soon disappear as pressure is removed from the sen- 
sory fibres of the internal capsule. The muscles upon the non-para- 
lyzed side of the body are somewhat weakened, though still capable of 
voluntary movement. The muscles of the forehead and the orbicular 
muscles of the eyelids do not share in the paralysis of the other facial 
muscles. The tongue, when protruded, deviates toward the paralyzed 
side in consequence of the failure of the genio-glossus muscle upon that 
side. The intercostal and abdominal muscles also suffer, so that their 
movement is less vigorous upon the paralyzed side than upon the other. 
Unless descending degeneration is developed in the pyramidal tract and 
invades the anterior cornu, the muscles remain without atrophy or loss 
of their normal electrical excitability, though they may dwindle some- 
what from disuse. 

Despite the loss of voluntary control over the muscles upon the para- 
lyzed side, they may yet exhibit involuntary movements in association 
with similar movements upon the healthy side of the body. Thus in 
laughing, coughing, or sneezing they may contract vigorously, and 
sometimes reflex movements may be aroused in the paralyzed muscles 
by tickling or by other forms of excitation. 

The cutaneous reflexes are sometimes diminished and sometimes re- 
main without change. The tendinous reflexes are considerably exagger- 
ated when the pyramidal tracts undergo degeneration. Trophic changes 
are sometimes observed in the paralyzed portions of the body and ex- 
tremities. Sensory disturbances are rarely present, though sometimes 
the sense of taste suffers in consequence of paralysis of the chorda 
tympani. The processes of nutrition are rarely affected. 

The disappearance of paralytic symptoms is gradual. In the major- 
ity of cases the leg first recovers, and the arm improves at a later 
period. The opposite course of events is considered an unfavorable 
occurrence. 

Secondary degenerations in the course of the pyramidal tracts are 
developed when hemorrhage involves the motor zone, or the motor por- 
tion of the corona radiata and internal capsule. Its symptoms first 
appear about six or eight weeks after the occurrence of paralysis. The 
tendinous reflexes become exaggerated, and gradually the phenomena 
of contracture are developed in the muscles of the paralyzed limbs. 
They are most pronounced in the flexor muscles of the fingers, hand, 



884 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

and forearm, and in the adductor muscles of the upper arm. The 
extensor muscles of the leg and thigh get the upper hand of their an- 
tagonists, so that it becomes necessary for the patient to swing the 
paralyzed limb forward by a semi-rotary movement of the pelvis. 

During the period of secondary degenerative changes, the psychical 
functions of the brain are frequently involved. The intellectual faculties 
become considerably weakened, and the power of controlling the emo- 
tions is greatly diminished. 

The duration of life after an attack of cerebral hemorrhage may be 
very short, or it may be prolonged for many years. Relapses are very 
common, and any one of them may prove fatal, or life may be termi- 
nated by progressive debility or by intercurrent diseases. 

Diagnosis. The distinction between apoplectic seizures and the 
effects of intoxication with opium or alcohol has already been described. 
The apoplectiform seizures which sometimes accompany cerebral oedema 
(serous apoplexy) may be distinguished by the absence of permanent 
paralytic symptoms. The same thing is true of apoplectiform attacks 
that are developed in the course of multiple cerebrospinal sclerosis, epi- 
lepsy, tabes dor satis, and progressive paresis. Apoplectic seizures from 
embolism or thrombosis of the cerebral arteries may be recognized by 
the concurrence of endocarditis or thrombosis in other parts of the body. 
Such attacks are usually more common among young people, while 
genuine cerebral hemorrhage is ordinarily a disease of advanced life, 
though it may occur at an early period in syphilitic subjects. 

Prognosis. The prognosis is always serious, and especially so 
when the hemorrhage is extensive, or when it approaches the vital 
centres in the medulla oblongata. 

Treatment. When a predisposition to cerebral hemorrhage exists, 
an excessive and exciting diet should be avoided, and the bowels should 
be kept easily open so as to avoid all violent straining and consequent 
increase of pressure in the bloodvessels. When an apopletic seizure has 
occurred, if the pulse be full and strong, with evident congestion of the 
bloodvessels in the head and face, a copious bleeding should be at once 
performed, and the patient should be placed with his head elevated by 
several pillows. Leeches and cups are less effectual, though useful 
with elderly persons. When the countenance is pale and the pulse is 
soft and weak, blood should not be taken ; it may become necessary to 
have recourse to the hypodermic injection of camphor, and to ergot, with 
the application of mustard to the extremities and surface of the body. 
After the subsidence of acute symptoms and the return of con- 
sciousness, the bowels must be kept open by the aid of rhubarb, or the 
compound infusion of senna with sulphate of magnesium. During the 
course of the second week it will be proper to commence the adminis- 
tration of iodide of potassium, in five-grain doses three times a day, to 
facilitate the removal of the products of extravasation. In syphilitic 
cases mercurial inunctions should also be employed. After the expira- 
tion of six or seven weeks, when the symptoms of irritation have dis- 
appeared, considerable benefit may be obtained from the employment of 
weak galvanic currents through the head. The current should be passed 
between the mastoid processes, or between the sympathetic ganglia be- 



DISEASES OF THE CEREBRUM. 885 

low the angle of the jaw and the probable seat of the hemorrhage, for 
three minutes at a time, and then for an equal length of time in the 
opposite direction. The strength of the current should never be suffi- 
cient to excite pain or dizziness, and the applications may be repeated 
every other day. Muscular contractions and atrophy may be best re- 
lieved by massage. Hot and cold baths are to be avoided, but moder- 
ately warm baths are not objectionable. 

Embolism and Thrombosis of the Cerebral Arteries. 

Etiology. Embolic obstruction of the cerebral arteries is usually 
caused by valvular diseases involving the left side of the heart. Em- 
bolism may result from a previous thrombus in the auricular appendix 
of the left ventricle, or from other diseases involving the large venous 
and arterial vessels of the heart. In certain cases the cerebral vessels 
may be obstructed by embolic masses of fat, derived from fractured 
bones ; and sometimes the excessive production of pigment that follows 
the destruction of red blood-corpuscles in the course of malarial fever 
occasions embolic obstruction of the small cerebral vessels. 

Cerebral thrombosis is generally a consequence of severe and exhaust- 
ing diseases that develop a condition of cachexia. It frequently follows 
endarteritis, as a consequence of old age, or Bright's disease, or 
syphilis, or chronic alcoholism ; and sometimes it results from vascular 
compression caused by tumors or inflammatory exudations in the neigh- 
borhood of the vessels. 

Pathological Anatomy. Cerebral embolism and thrombosis most 
frequently occur in the course of the Sylvian artery or its branches, 
usually upon the left side of the brain, since the communication is 
most direct between the heart and the left Sylvian artery. Right 
hemiplegia and aphasia are common consequences of such an event. 

When a portion of the brain is cut off from the direct course of the 
circulation by obstruction of its vascular supply, if a collateral circula- 
tion cannot be established, necrosis of the tissue or hemorrhagic infarc- 
tion are inevitable. For this reason, everything depends upon the seat 
of obstruction. If it be in the vessels below the circle of Willis, 
collateral circulation may still provide for the nutrition of the cerebral 
substance ; but if an obstruction be situated in one of the terminal 
arteries of the brain above the circle of Willis, collateral circulation can- 
not be established, blood coagulates in the vessels through which it can 
no longer circulate, and an infarct is thus produced ; or the tissues un- 
dergo necrotic softening which may be either white, gray, red, or yellow, 
according to the amount of pigmentation or fatty degeneration that in- 
volves the softened mass. Similar softening follows inflammation of the 
cerebral substance, but it differs microscopically through the predomi- 
nance of cellular proliferation and the absence of embolic or thrombotic 
obstruction in the neighboring vessels. 

In white and gray softening of the cerebral substance the necrosed 
tissues can be readily washed out with a stream of water, leaving an 
irregular cavity in the substance of the brain. Microscopical examina- 
tion indicates fatty degeneration of the nerve fibres and ganglionic 



886 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

cells. The cellular structures of the neuroglia and of the bloodvessels 
also undergo fatty degeneration, so that finally nothing remains but 
minute oil globules and fat-laden cells. As the process advances, the 
white or gray color of the softening mass becomes transformed into a 
yellowish tint through the accumulation of the fatty products of de- 
generation. Sometimes the neighboring connective tissue thickens and 
forms a cystic envelope, similar to that which surrounds an apoplectic 

c y st - 

Red softening of the brain is a condition which corresponds to the 
hemorrhagic infarcts that occur in other organs. The color of the 
softened mass is due to the presence of red blood-corpuscles which grad- 
ually break up and are transformed into fatty detritus, while their 
coloring matter becomes crystallized or deposited in the form of dark- 
brown or yellow masses. The form of the softened spot is usually oval, 
and its size varies according to the extent of the territory that has been 
deprived of its blood supply. Not unfrequently a number of softened 
masses of different age exist in correspondence with successive embolic 
or thrombotic occurrences. 

When the obstructive plug has been derived from an infective source, 
as in pyaemia or ulcerative endocarditis, or from a gangrenous mass, 
such as exists in pulmonary gangrene, an inflammatory, suppurative, or 
gangrenous process is set up in the substance of the brain by the infec- 
tive micrococci that have thus found access to the organ. 

Symptoms and Diagnosis. Cerebral embolism usually differs from 
thrombosis by its sudden occurrence; while the formation of a thrombus 
is more slowly conducted, and is often accompanied by symptoms that 
resemble the prodromata of an apoplectic seizure. It is impossible to 
distinguish by the aid of symptoms alone between an apoplectic attack 
that is caused by cerebral hemorrhage and one that is caused by cerebral 
vascular obstruction. The subsequent course and symptoms of the dis- 
ease are identical in both cases. The probability of embolism is very 
great when an apoplectic seizure occurs in a young person who suffers with 
cardiac disease, especially if previous embolic processes have occurred 
in other organs of the body. Thrombosis maybe suspected when arte- 
rio-sclerosis exists in the bloodvessels, or when syphilis is present. 

Prognosis and Treatment. Prognosis and treatment are the same 
as in cases of cerebral hemorrhage, only that venesection should never 
be performed. Stimulants, rather than sedatives, should be adminis- 
tered to counteract the shock by which the patient is prostrated. 

Cerebral Inflammation — Encephalitis. 

Etiology. Inflammation of the brain is a rare occurrence, and is 
usually dependent upon injuries of the skull, or upon the extension of 
inflammation from the ear or other bones of the cranium. It may also 
result from the entrance of infective embolisms into the cerebral arteries. 
Such transportation may be effected from the peripheral portions of the 
body through the right side of the heart, when the foramen ovale re- 
mains open. In certain cases encephalitis may be excited by other 



DISEASES OF THE CEREBRUM. 837 

diseases within the brain itself; but sometimes the cause of inflamma- 
tion eludes observation. 

Pathological Anatomy. Encephalitis may be limited to the pro- 
duction of inflammatory softening, or it may result in the formation of 
an abscess. Inflammatory softening corresponds with that which has 
been already described as a consequence of embolism or thrombosis. 
The softened mass may be of a red, brown, or chocolate color. It is 
swelled by serous effusion, and produces evident bulging of the over- 
lying convolutions and reduction in the depth of the adjacent fissures. 
As the process advances, the mass assumes a yellowish color, in conse- 
quence of the destruction of the extravasated red blood-corpuscles and 
the transformation of their coloring matter, which becomes stored up in 
yellow masses within the surviving ganglionic cells. The process of 
fatty degeneration also adds to the yellowness of the degenerated tis- 
sues. The lymph spaces and the white blood-corpuscles become loaded 
with minute oil globules and crystals of the fatty acids. The softened 
mass can be readily washed out from the adjacent tissues, leaving an 
irregular cavity in the substance of the brain. When recovery takes 
place, the degenerated residuum is gradually absorbed, and a firm, pig- 
mented mass of cicatricial tissue occupies the seat of inflammation. 
The overlying cortical portion becomes depressed, and the pia mater is 
thickened and adherent to its surface. Sometimes, instead of cicatricial 
tissue, a cyst is formed, like that which surrounds an old hemorrhagic 
extravasation. 

Inflammatory softening usually involves only a single circumscribed 
portion of the brain, but sometimes, as in cases of pyaemia, numerous 
small inflammatory foci may exist. 

Suppurative inflammation of the brain may be either diffuse or cir- 
cumscribed. Diffuse suppuration tends to progressive extension and 
final perforation through the walls of the ventricles, or through the 
cerebral cortex into the meningeal cavity. 

Circumscribed abscesses are surrounded by a capsule of thickened con- 
nective tissue. Their size is extremely variable. Sometimes a circum- 
scribed abscess may become transformed, apparently by rupture of its 
wall, into a diffuse suppurative process, so that no precise distinction 
between the two forms of suppuration is possible in such cases. If air 
finds access to the cavity of the abscess, or if it be dependent upon 
gangrenous processes in other parts of the body its contents emit an 
offensive odor. Sometimes the presence of foreign bodies derived from 
without, or from fractured portions of the cranial bones, may be 
discovered in the cavity of the abscess. In chronic cases caseation and 
calcification of the pus may occur; or it may be gradually absorbed 
and thus cicatrization may occur. 

Symptoms. Cerebral inflammation frequently exists without mani- 
fest symptoms. Sometimes death occurs after a long previous course of 
emaciation and exhaustion without apparent cause, and only after death 
is the existence of an abscess revealed. Sometimes the symptoms of 
typhoid fever or of an intermittent, hectic fever characterize the course 
of the disease. 

But, in typical cases, general cerebral symptoms of pressure within 



DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

the cranium are accompanied by local symptoms of injury to the brain 
substance. Even then, the diagnosis is often obscure, unless injuries 
of the cranial bones, diseases of the inner ear, or gangrenous processes 
in other parts of the body furnish sufficient ground for the suspicion of 
cerebral inflammation. 

Sometimes inflammation is followed by an apoplectiform seizure 
which may result fatally. In many cases the intellectual faculties 
become deranged, and hysterical symptoms may be exeited. Sometimes 
convulsive seizures are witnessed. Headache is one of the most common 
symptoms. It is sometimes accompanied by a sensation as if something 
were moving in the head. Dizziness, nausea, vomiting, sleeplessness, and 
irregularity of the pulse are sometimes experienced. Pain and perver- 
sions of sensation frequently involve the extremities ; and by the aid of 
the ophthalmoscope choked disc or retinal inflammation may be discov- 
ered, sometimes corresponding to the side upon which the abscess is 
forming. Muscular paralysis, spasm, and contracture frequently follow 
invasion of the motor tract within the brain. Rupture into the ventri- 
cles is followed by convulsions and speedy death. Similar consequences 
follow the invasion of the meninges. The duration of the disease is 
usually brief, but sometimes it pursues a very chronic course. 

Diagnosis and Prognosis. The recognition of cerebral inflamma- 
tion is attended with great difficulty, and may be sometimes impossible. 
The differential diagnosis between chronic cerebral abscess and cerebral 
tumor is often attended with great uncertainty. Spontaneous recovery 
is almost out of the question, and surgical interference is attended with 
great danger. 

Treatment. When cerebral inflammation is suspected, cold appli- 
cations should be made to the head, and blood may be drawn by the aid 
of leeches from the vicinity of the disease ; the bowels should be kept 
open, and mercurial inunction should be practised daily, together with 
the administration of iodide of potassium. For the evacuation of an 
abscess it is necessary to trephine the bones of the cranium, and to 
plunge a scalpel into the substance of the brain. This operation will 
be greatly facilitated when local symptoms indicate the probable seat of 
suppuration. 

Cerebral Tumors — Neoplasmata Cerebri. 

Tumors within the cavity of the cranium may originate in the sub- 
tance of the brain itself, or in the cerebral meninges, or from the bones 
of the cranium, or they may force their way in from without the cranial 
cavity. Their growth is sometimes excited by injuries, or it may fol- 
low infective diseases, notably tuberculosis and syphilis. Sometimes 
they originate as a secondary growth after malignant disease in dis- 
tant organs of the body. They are more frequently observed among 
men than among women. Tubercular neoplasms commonly occur in 
early life, while cancerous tumors are developed during later years. 

Pathological Anatomy. According to the frequency of their oc- 
currence may be enumerated the following species of cerebral tumors : 
Glioma, sarcoma, psammoma, myxoma, carcinoma, melanoma, and 
cholesteatoma. Other neoplasmic forms are exceedingly rare. 



DISEASES OF THE CEREBRUM. 

Glioma usually occurs in the white substance of the brain, where it 
forms a single tumor that contracts no adhesions with the meninges when 
it reaches the cerebral surface. It is not unfrequently accompanied by 
hemorrhage, and as it grows it produces symptoms of irritation and of 
paralysis. When such a tumor undergoes fatty degeneration it may 
easily be mistaken for yellow softening of the brain The growth is de- 
veloped from the neuroglia. Its limits, consequently, are not clearly 
defined, and intermediate forms exist with the characteristic appearances 
of myxoma (myxo-glioma). 

Sarcoma usually occurs as a primary disease in the brain, though 
sometimes melano-sarcomatous tumors appear as secondary formations. 
The disease may spring from the cerebral tissues or from the meninges. 
The tumor is frequently surrounded by a vascular capsule, and the con- 
sistency of the mass is exceedingly variable. Sarcoma grows more 
rapidly than glioma, and its vascular forms are frequently accompanied 
by hemorrhage. 

Psammoma is usually connected with the dura mater over the con- 
vexity of the brain. The mass is chiefly composed of connective tissue 
in which are imbedded gritty concretions that are composed of calcium 
carbonate. 

Carcinoma usually occurs as a single primary tumor seated upon the 
dura mater, pia mater, or cerebral tissue. Sometimes the tumor origi- 
nates outside of the cranium, or it may develop upon the exterior sur- 
face of the dura mater and perforate the skull, bulging under the scalp. 
Medullary cancers are encountered more frequently than the scirrhous 
form. 

Myxoma and Melanoma are very rarely observed. Cholesteatoma 
constitutes a solid, pearly-looking mass which may reach the size of a 
walnut. 

Tumors that spring from the bones or from the meninges produce 
compression of the cerebral substance, displacing its mass, and destroy- 
ing its function by the exclusion of blood from its vessels, and by atro- 
phy of its tissues. When the base of the brain is involved, the cere- 
bral nerves are liable to disturbance and destruction of their function 
through the action of similar causes. When a tumor occupies the sub- 
stance of the brain, it causes progressive bulging of the surface, flatten- 
ing and dryness of the convolutions, and obliteration of the sulci. 
Sometimes hemorrhage, inflammation, softening, and anaemia exist in 
the neighborhood. Meningitis may exist, and dropsy may be developed 
through pressure upon the venae Galeni. 

Symptoms. Cerebral tumors may exist without symptoms when they 
do not involve the sensory or motor tracts, or produce appreciable in- 
crease of pressure within the cranium. The first of the general symp- 
toms that indicate the existence of a tumor is headache. This is almost 
constant, though sometimes intermittent or increased during the night- 
time, or by any form of excitement or excess. Its intensity is some- 
times beyond description, but in certain cases it exists only as a dull, 
diffused pain. Sometimes it is localized in a particular portion of the 
head, though this does not always correspond with the situation of the 
neoplasm. In certain cases a circumscribed area of tenderness, that 



890 DISEASES OF BRAIN AXD CEREBRAL MEMBRANES. 

usually corresponds with the situation of the tumor, may be detected 
by tapping on the bones of the cranium. Vomiting is frequently asso- 
ciated with severe paroxysms of headache. 

Dizziness, or vertigo, is commonly observed. Its intensity is varia- 
ble, and it produces great liability to fall in one direction or another. 
It is usually most severe when the tumor is situated in the posterior 
cranial fossa. 

Mental derangement is a not uncommon symptom. The patient 
becomes irritable, moody, hysterical, apathetic, somnolent, delirious, 
maniacal, or comatose. These symptoms are developed with variable 
degrees of intensity, and are liable to intermissions and exacerbations. 
In many cases they are not conspicuous. 

Apoplectiform and convulsive seizures are frequently observed. 
either as a consequence of actual hemorrhage in the neighborhood of a 
tumor, or by reason of the irritation excited by its presence. Chorei- 
form movements are sometimes observed in the extremities when a 
tumor is situated in the posterior portion of the internal capsule or in 
the pons Varolii. 

Severe peripheral pains of a rheumatic character, and intolerable 
itching are sometimes experienced. 

One of the most important symptoms of an intra-cranial tumor con- 
sists in the development of choked disc. This symptom is observed in 
nearly every case. It is produced by an increase of intra-cranial pres- 
sure that occasions stagnation of the cerebro-spinal fluid between the 
external and internal sheaths of the optic tract. By this pressure, the 
retinal veins are hindered from discharging the blood which they con- 
tain, and the optic papilla consequently becomes swelled and inflamed, 
producing atrophy of the optic nerve, and more or less loss of vision. 
Sometimes retinal hemorrhages are also observed. The symptoms vary 
in severity, and complete blindness may suddenly occur and disappear, 
as the amount of pressure temporarily increases or diminishes. 

The other nerves of special sense are sometimes more or less paral- 
yzed by the increase of intra-cranial pressure, or by inflammation, or by 
direct compression exerted by the tumor itself. 

Excepting cancerous cases, the general health frequently remains 
without serious modification ; but sometimes a urcemic pallor is devel- 
oped. If the floor of the fourth ventricle be disturbed by a tumor. 
sugar usually appears in the urine. Irregular respiration, and re- 
tardation of the puke are observed during the later stages of the disease, 
and sometimes the temperature is considerably elevated before the 
termination of life. 

Local symptoms are developed according to the situation of a tumor, 
and according to the function of the nerves or tracts that are specially 
involved. During the earlier and progressive stages of the disease, the 
symptoms of irritation are most conspicuous ; at a later period the 
symptoms of paralysis appear. Irritation is indicated by spasms and 
contractures ; paralysis by weakness and loss of function. When the 
cranial nerves are subjected to direct pressure upon their nuclei or 
trunks, the consequent paralytic symptoms are accompanied by muscular 
atrophy and the reaction of degeneration ; both of which conditions are 



DISEASES OF THE CEREBRUM. 891 

absent when paralysis is occasioned by pressure involving the tracts be- 
tween their nuclei and the cerebrum. When the sensory nerves are 
invaded, the phenomenon of anaesthesia dolorosa is developed, since the 
nerve is no longer capable of conveying impressions from the surface of 
the body, though its irritation at the point of compression occasions 
subjective sensations of pain that are referred to the periphery. 

The duration of intra-cranial tumors seldom exceeds two years, 
though in rare instances a much longer period has been recorded. 
Death usually occurs during a convulsion or an apoplectiform attack, or 
as a consequence of progressive exhaustion and coma. 

Diagnosis. Cerebral tumors must necessarily sometimes escape 
recognition. The existence of choked disc is one of the most valuable 
indications of an intra-cranial neoplasm. The disease may be frequently 
mistaken for cerebral hemorrhage, thrombosis, embolism, abscess, or 
urcemici. When retinal symptoms are absent, it is sometimes difficult 
to differentiate the case from ordinary forms of epilepsy, hysteria, or 
mania. 

Prognosis and Treatment. The prognosis is unfavorable. Only 
when a tumor occupies a superficial location in the motor zone of the 
brain, is it possible to undertake the relief of the patient by surgical 
methods. In the majority of cases it becomes necessary to remain con- 
tent with simple dietetic and hygienic measures, relieving pain and 
vomiting with morphine hypodermically, and giving large doses of 
potassium bromide during periods of excitement or convulsion. Sali- 
cylic acid sometimes is beneficial when headache is severe. 

Cerebral Aneurism. 

Aneurismal tumors sometimes develop upon the cerebral arteries, 
and exert pressure upon the adjacent tissues or cranial nerves. They 
are usually connected with the circle of Willis and its branches, espe- 
cially with the left Sylvian artery and the basilar artery. In three- 
fourths of the cases rupture and hemorrhage occur. 

The symptoms are frequently very obscure, consisting of general dis- 
turbances like headache, dizziness, vomiting, neuralgia, loss of vision, 
spasm, and paralysis in connection with the cerebral nerves. Some- 
times the symptoms assume the form of epilepsy, or mental derangement. 
When rupture takes place, the ordinary symptoms of apoplexy are 
developed, and frequently terminate in death. In many cases hissing 
sounds within the head are audible to the patient, and occasionally 
they may be recognized by auscultation. 

Hydrocephalus. 

Hydrocephalus consists of a serous transudation either between the 
meninges (inter-meningeal hydrocephalus), or into the cerebral ventricles 
(ventricular hydrocephalus). These two conditions may be associated 
together, since a communication exists between the sub-arachnoid space 
and the cavity of the ventricles. Occasionally the fluid is restricted 
within circumscribed limits, by reason of adhesions within the ventricles 



892 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

or between the meninges ; but in the majority of cases the fluid moves 
freely throughout those spaces. When the disease occurs in early life, 
while the bones are yet soft and yielding, the cranial cavity may be- 
come greatly distended, so that the fontanelles are prominent, and the 
different bones may be widely separated from each other, even after 
their sutures had been partially consolidated. But in older patients 
such distention is seldom possible, and the effects of pressure are mani- 
fested by reduction of the thickness of the bones, and by atrophy of 
the cerebral mass. 

The disease may develop very rapidly in an acute form, or it may 
take a chronic course. It is sometimes originated before birth as a 
ventricular dropsy, by which the head is enormously distended, so that 
the substance of the brain forms a mere bladder-like wall surrounding 
the cavity of the ventricles. Such cases are frequently associated with 
other congenital malformations and defects. If the infant comes living 
into the world, life is usually very brief, and is passed in a condition of 
idiotic helplessness. 

In many cases, however, hydrocephalus results from processes that 
originate after birth. It is very commonly produced by intra-cranial 
inflammation, especially when that is of tubercular origin, hence the 
term acute hydrocephalus, formerly applied to cases of acute meningi- 
tis. Ventricular hydrocephalus is frequently dependent upon diseases 
of the choroid plexus or of the ventricular ependyma. It may be oc- 
casioned by compression of the vena magna Galeni, or of the straight 
sinus, by neoplasms or inflammatory products within the cavity of the 
cranium ; and it may also result from any condition outside of the skull 
that interferes with the return of blood through the large veins of the 
neck. In certain cases hydrocephalus depends upon the cachectic and 
dropsical tendencies that accompany chronic and malignant diseases. It 
is often associated with rickets ; and among old people, in whom cere- 
bral atrophy sometimes occurs, the space left vacant by the dwindling 
brain is occupied by a hydrocephalic transudation. 

Pathological Anatomy. When hydrocephalus is developed dur- 
ing infancy, the skull assumes a very characteristic form. The cranial 
portion is immensely enlarged and contrasts strongly with the pigmy fea- 
tures of the face. ■ The fontanelles are greatly enlarged, and sometimes 
the bones are completely separated from one another. The roof of the 
orbit is depressed, and the eye seems unnaturally prominent. The 
almost hairless scalp is covered with dilated and tortuous veins. 
Rachitic changes in the bones of the skeleton are frequently evident, and 
in severe cases the patient lies perfectly helpless and stupid. The 
brain is compressed, and its anaemic convolutions are flattened in eases 
of inter-meningeal hydrocephalus ; in cases of ventricular distention 
the sulci are obliterated by the great distention and outward pressure 
of the fluid in the ventricles, and the basal ganglia are flattened and 
atrophied. The ventricular ependyma is frequently thickened and 
granulated. Sometimes the distended hemispheres are actually rup- 
tured. The fluid transudation is usually clear and serous, like ordinary 
dropsical fluids. It consists of about 99 per cent, of water, with a trace 
of albumin and other serous constituents. 



DISEASES OF THE CEREBRUM. 893 

Symptoms. Acute hydrocephalus frequently runs its course so 
rapidly that the characteristic changes in the form of the skull are not 
developed ; they are most conspicuous in chronic forms of the disease. 
Besides the evidences of helpless imbecility that exist, spasms, convul- 
sions, and contractures are frequently observed. Complete paralysis is 
less frequent. When the patient is of an age that does not permit the 
yielding and separation of the cranial bones, the pressure phenomena 
of choked disc, optic atrophy, and loss of vision are usually developed. 
Recovery sometimes takes place, either through the gradual absorption 
of the liquid, or after its spontaneous discharge through the mouth, 
nose, orbits, or ears. In many cases, however, death occurs, and may 
be preceded by convulsions, coma, or apoplectic seizures. 

Treatment. Infantile hydrocephalus may be treated by puncture 
and drainage of the cranium, followed by strapping the head with 
adhesive plaster. Iodide of potassium and other remedies that are sup- 
posed to favor absorption exert no appreciable influence. Rickets and 
other predisposing conditions require appropriate treatment. 

Cerebral Hypertrophy — Hypertrophia Cerebri. 

Hypertrophy of the brain is usually a congenital condition observed 
in early childhood. It is frequently associated with rickets ; and among 
adults it occurs in connection with alcoholism, epilepsy, and excessive 
psychical disturbances. Injuries and other causes have occasionally been 
blamed for its existence. The condition is usually observed in the hemi- 
spheres of the cerebrum, involving an increase of the neuroglia in the 
white substance. When the skull is opened, the brain bulges as if it 
had been relieved from excessive pressure. The membranes are aneemic 
and the cerebro-spinal fluid is deficient in quantity. The consistence 
of the organ is increased, so that it feels dense, and sometimes is elastic 
like India-rubber. When the disease develops at an early period, the 
cranium enlarges and assumes the form of the hydrocephalic skull. In 
adult cases the bones are excessively thin. The disease is frequently 
accompanied by an uncertain gait, epileptiform convulsions, headache, 
dizziness, and vomiting. Sensory disturbances are rare, but irregularity 
of respiration, retardation of the pulse, muscular contracture, and paral- 
ysis are developed as intra-cranial pressure increases. The intellec- 
tual faculties finally disappear, and death often occurs quite suddenly. 
In young children it is sometimes occasioned by spasm of the glottis ; 
and it frequently follows convulsions, apoplectiform seizures, menin- 
geal inflammation, and coma. 

Cerebral Atrophy — Atrophia Cerebri. 

Etiology. Cerebral atrophy may be congenital, and occurring in 
children it is frequently unilateral. It is often observed in old age, 
though by no means a necessary consequence of advancing years. It 
sometimes results from chronic wasting and malignant diseases, and it 
may be developed as a consequence of any form of chronic disease 
within the cranial cavity by which the brain is subjected to pressure. 



894 DISEASES OF BR A IX AXD CEREBRAL MEMBRANES. 

Secondary atrophy exists in the brain when important organs or mem- 
bers with which it is in connection have been removed, e. g.. extirpa- 
tion of the eyeball, amputation, etc. In like manner it may result 
from ligature of the carotid artery, or from impaired nutrition by reason 
of chronic intoxication with opium, alcohol, or lead. 

Pathological Anatomy. When the entire brain is involved in the 
atrophic process, it shrinks from the cranial walls, and the vacant space 
is filled by an increase of the cerebro-spinal fluid. The cerebral tissue 
appears firm and dense, the cortical structures are highly colored, and 
the white substance assumes a yellowish tint. The neighborhood of the 
vessels within the hemispheres is riddled with cavities like those in old 
cheese. The ventricular ependyma is thickened and granulated. In 
cases of infantile hemiatrophy the cranium becomes unsymmetrical, 
and the bones upon the atrophied side are increased in thickness. In 
many cases secondary degeneration follows the pyramidal tracts into the 
cord and invades the spinal nerve roots, producing spastic symptoms, 
contracture, or paralysis of various muscles in the extremities. 

Symptoms and Diagnosis. Infantile hemiatrophy of the brain is 
almost invariably associated with physical and mental imperfection. 
Idiocy is the rule. The muscles of the extremity and of the face upon 
the side opposite to the atrophied portion of the brain are more or less 
completely paralyzed and atrophied. The arms are more seriously 
affected than the legs. The muscles frequently undergo contracture, 
by which the movements of the limbs are greatly hindered : and the 
nutrition of the disordered extremities is impaired to such a degree 
that with advancing years the paretic limbs retain infantile dimensions. 
The sensory functions seldom exhibit any considerable deterioration, 
though the special senses are frequently defective. Convulsions are 
not uncommon, and death is often preceded by coma, or by apoplecti- 
form or epileptiform seizures. 

Senile atrophy of the brain is characterized by loss of memory. 
childishness, tremor, and weakness of the bladder and rectum. Some- 
what similar consequences follow the atrophy that develops as a conse- 
quence of alcoholism, or cerebral hemorrhage, or any other chronic 
disease that interferes with the blood supply and nutrition of the brain. 

Diffuse Cerebral Sclerosis — Sclerosis Cerebri Diffusa. 

Diffuse sclerosis of the brain is produced by a proliferation of the 
neuroglia, a process that results in atrophy of the nervous elements, 
and the development of the ordinary symptoms of cerebral atrophy. 
The affected tissues are elastic, and the disease sometimes invades the 
spinal cord. It is supposed to be usually dependent upon chronic 
alcoholism. A positive diagnosis during life is impossible. 

Acute Cerebral Infantile Paralysis — Paralysis Infantilis Spastica 

Cerebri. 

This disease occurs among children during the period of first den- 
tition, and is often observed after the ordinary infective diseases. It is 
probably dependent upon an infective cause. 



FUNCTIONAL DISEASES OF THE BRAIN". 895 

Symptoms. The disease usually commences suddenly, with fever, 
vomiting, stupor, and convulsions which are frequently unilateral, and 
usually involve the right side of the body. After a day or two, hemi- 
plegia paralysis, more pronounced in the arm than in the leg, is dis- 
covered. Sometimes only one limb is affected. Occasionally the disease 
takes the form of paraplegia, and sometimes the cranial nerves are 
involved. A transient motor aphasia often accompanies right-sided 
hemiplegia, and it is occasionally observed without paralysis of the 
extremities. 

Convalescence is soon established, and the paralytic symptoms be- 
come more and more circumscribed, but remain permanent in certain 
muscular groups. These undergo atrophy, and the paralyzed limbs re- 
main permanently smaller than their fellows, though the development 
of subcutaneous fat is quite luxuriant. The skin remains blue and cold. 
Sensation is not changed. The paralyzed muscles soon become rigid, 
so that it is difficult to bend the joints of the affected limbs. Contrac- 
tures are developed, and the tendinous reflexes are frequently exagger- 
ated. The electrical excitability of the nerves and muscles remains 
without change. Hemichorea, hemiathetosis, ataxia, and other unusual 
forms of motion are often observed. The children frequently remain 
idiotic or become epileptic, and their convulsive attacks usually com- 
mence in the paralyzed limbs. 

Pathological Anatomy. The disease is frequently caused by cor- 
tical atrophy, porencephalia, diffuse sclerosis, inflammation, hemorrhage, 
thrombosis, or embolism — processes that involve the motor zone and 
paths of voluntary impulse within the brain. 

Diagnosis, Prognosis, and Treatment. The disease may be 
easily distinguised from acute anterior poliomyelitis by the presence or 
increase of the tendinous reflexes, and by the absence of the reaction 
of degeneration. The prognosis and treatment are the same as that 
which has been already described in the section, on poliomyelitis. 



CHAPTEE IV. 

FUNCTIONAL DISEASES OF THE BRAIN. 

Epilepsy — Epilepsia. 

Etiology. Epilepsy is a chronic functional disease of the brain, 
and is characterized by paroxysms of unconsciousness, frequently accom- 
panied by tonic and clonic convulsions. The disease usually begins 
during the period of childhood and adolescence, but occasionally it com- 
mences in advanced life. After the period of maturity its origin is 
usually dependent upon syphilis or upon cysticerci, or other neoplasms 
within the cranium. 

Epilepsy may be either a primary disease of the brain, or it may 



DISEASES OF BEAIX AXD CEREBRAL MEMBRANES. 

occur as : »f irritative diseases that excite the 

brain. 

P an hereditary disease, very commonly 

encountered among the members of neurotic families whose ancestors have 
suffered from vai ions forms - sease, or who have been drunk- 

i Is :r insane. 
Epilepsy is sometimes riginated by 

It sometimes occurs as a consequence of frequent mi 
of the disease. 2? keU and other causes of constitu: Icb&ty 

gly predispose to epilepsy, and it has been frequently observed as 
nence of chronic wm. 

9 is often caused by -. th : ugh the primary 

form of the disease may be developed as a consequence of violent shocks 
: : produce only molecular changes in the brain. 

Reflex epilepsy is a variety of the secondary form of the disease that 
is excited by any cause of peripheral irritation that reaches the brain. 
In all such cases, however, it is probable that a morbid predisposition 
already exists in the cerebral structures. Among such cases may be 
enumerated epilepjsies that are excited by pressure upon sens:: 
or by accumulations of ear-wax. or by diseases And tumors in the nasal 
and respiratory passages. The alimentary canal is not unfrequently 
seat of such irritative agents : and the removal of decayed teeth. 
indigested! : i. intestinal parasites, and stagnant feces in fol- 

, in fortunate cases, by the cure of the disease. 
The changes and excitements that aeeoinpai ~ aent 

at t: ';i are frequent causes of epilepsy. Phimosis. 

pregnancy, and other disturbances of the sexual apparatus are not 
uncommon excitants of the disease. It is not unfrequently aroused by 
masturbation, and its origin has sometimes dated from the fin 
llation. 
In many cases epilepsy is dependent upon injuries, inflammations. 
tumors, abscesses, c g the cavity of the cranium and its con- 

Direct irritation of the cerebral cortex in the motor zone - 
common cause : I s sksonian epilepsy). 

When a predisposition to epileptic seizures exists, the paroxysms of 
the disease may be frequently excited by the most varied and accidental 
causes of cerebral agitation. 

Pathological Anatomy. The anatomical conditions by which the 
■ ilepsy is determined are unknown. \ arious pathoi _ 
Virions have be* - rved in the brain in connection with epil 
but they ] asess n gree of uniformity, are usually absent, and throw 
no light upon the nature or causes of the primary form of the disc - 

SYMPTOMS. The sympt: I f • , V ary from a slight and 

scarcely noticeable disturbance of consciousness to the most violent and 
terrifying displays of physical and mental excitement and derangement. 
Two principal forms of the disease are recognized : t : ■ iepsia 

gravis, grand mall, and thi mild form (epilepsia mitis. petit mal). 

v is characterized by the occurrence of 

convulsions, hence it is frequently termed eoiivuUiw epilepsy. The 

wsms are usually preceded by disturbance of the emotions — the 



FUNCTIONAL DISEASES OF THE BRAIN. 897 

patient becomes moody, fretful, sleepless or stuporous, forgetful and 
apathetic ; the pupils are sometimes contracted for several hours before 
an attack. The paroxysm frequently occurs without special warning, 
but it is sometimes preceded by peculiar disturbances of sensation or 
motion, constituting what is termed an aura, because it is frequently 
described as a sensation like that of air blowing upon the body. In 
many cases a sensory aura is characterized by perverted cutaneous 
sensations — feelings of constriction about the heart, a sense of disten- 
tion in the abdominal region, unnatural feelings in the sexual apparatus, 
or a feeling as if something were crawling over the skin of the extremi- 
ties. These peculiar feelings frequently mount upward from their 
point of origin until they reach the head, when the paroxysm immedi- 
ately follows. 

Motor auras are usually characterized by slight spasmodic movements, 
or transient paralysis in the muscles of the extremities or face. Sen- 
sory auras are manifested in the sphere of special sensation. There 
may be complaint of some unusual sensation of taste, or smell, or hear- 
ing, or of brilliant colors, usually scarlet, flashing before the eyes. 
Hallucinations are not uncommon ; and sometimes there is delirium, 
during which the patient becomes violent, and commits acts of maniacal 
fury of which he is utterly ignorant, and which are not remembered after 
the paroxysm. Vasomotor auras consist in the development of circu- 
latory disturbances in the skin — the extremities become pale and cold, 
or cyanosed, with a feeling of numbness that seems to creep upward 
toward the vital centres. 

The duration of an aura is variable. It may be scarcely appreciable, 
or it may continue for several minutes, giving the patient time to pre- 
pare for the threatened paroxysm. In such cases it may be possible to 
avoid the attack by various measures, such as binding an extremity in 
which an aura develops, or swallowing a teaspoonful of salt or bromide 
of potassium. Sometimes, however, it is found that such abortive treat- 
ment, like all other forms of treatment that hinder the evolution of the 
epileptic paroxysm, is productive of so much discomfort that the patient 
prefers to experience an occasional paroxysm, by which he feels 
relieved and endowed with a larger amount of comfort. 

The epileptic paroxysm is usually ushered in by a frightful outcry 
that is occasioned, not by pain, but by a sudden tonic spasm of the 
respiratory muscles. At the same instant consciousness is completely 
lost, and the patient falls prostrate without the slightest precaution 
against injury. He may fall into the fire, or into any position of dan- 
ger, and is thus often subjected to the severest forms of injury, and 
even to the loss of life. The countenance is deadly pale ; sometimes the 
heart ceases to beat for a few seconds ; the eyes are rotated upward 
beneath the upper lids ; every muscle in the body is violently con- 
tracted, the head is drawn to one side or the other ; the mouth may be 
either wide open or forcibly closed, with the tongue between the teeth 
which frightfully lacerate its substance. This condition of tonic spasm 
continues for ten or fifteen seconds. It is then followed by clonic 
convulsions, during which the face becomes flushed, and the whole sur- 
face of the body is cyanosed as the eyes roll, the jaws clash, the features 



898 DISEASES OF BRAIX AND CEREBRAL MEMBRANES. 

jerk, and the extremities are violently displaced by alternate contrac- 
tion and relaxation of the muscles. As a consequence of spasms in the 
muscles of the neck and throat the return of blood to the heart is pre- 
vented, and the superficial veins stand out like cords beneath the pur- 
ple skin. Respiration is impossible ; the saliva cannot enter the 
pharynx, and is expelled between the lips in froth that is frequently 
tinged "with blood. In many cases minute subcutaneous extravasations 
of blood may be observed upon the forehead, cheeks, and thorax. The 
fingers and thumb are flexed into the palm of the hand, and if the 
thumb be forcibly extended it remains drawn spasmodically backward. 
"Urine, feces, and semen are sometimes unconsciously evacuated : the 
pupils are dilated and no longer react, though the other ocular reflexes 
are somewhat increased. The temperature remains without special 
change. 

The duration of the clonic convulsion varies from half a minute to 
five minutes : the skin becomes damp with perspiration ; agitation rap- 
idly subsides, and usually the patient remains in a deep sleep or stupor 
for half an hour or longer. On awakening, there is no recollection of 
the events that have transpired during the paroxysm, though there may 
be a sensation of fatigue and muscular soreness, often accompanied by 
mental torpor, for several day?. 

In certain cases the convulsive paroxysm is preceded or followed by a 
period of delirium or maniacal excitement, during which the infuriated 
individual is dangerous to everything and to every person in his vicinity. 
Under such circumstances homicide and other outrages have been com- 
mitted without the knowledge of the actor, or any recollection of the 
event after the cessation of this post- or pre-epileptic stadium of the 
paroxysm. In certain cases paralytic symptoms of greater or less 
severity are manifested for a few days after the paroxysm. 

Epileptic paroxysms sometimes occur only during the daytime, but in 
other cases they are only experienced during the night, usually about 
three or four o'clock in the morning. Sometimes they thus occur for a 
considerable period of time, without awakening a suspicion of their ex- 
istence. The patient complains only of fatigue and muscular soreness 
during the following day, or he is surprised by finding the bed soiled 
with involuntary discharges ; and only after the tongue has been severely 
bitten is it finally discovered that he is epileptic. Sometimes the 
paroxysms occur indiscriminately by day or by night. In certain cases 
their incidence is very rare, months or even years intervening between 
the paroxysms. In other cases they occur many times a day. They 
are sometimes excited by the occurrence of infective diseases, but occa- 
sionally they disappear after such an event. 

"When epileptic paroxysms succeed one another rapidly, at intervals 
of a few minutes or an hour or two, the temperature begins to rise, 
grave symptoms of danger are developed, and frequently terminate in 
death. This condition is termed the status epihpticus. 

Chronic epilepsy usually produces characteristic changes in the ap- 
pearance and demeanor of the patient : the expression becomes dull and 
apathetic, the features are coarse and expressionless, the nose is broad 
and flat, the lips are thick and sensual, not unfrequently the skull is 



FUNCTIONAL DISEASES OF THE BRAIN. 899 

unsymmetrical, and the ears are deformed. The mind suffers, memory 
fails, intellectual development is retarded, and sometimes a condition of 
permanent idiocy or dementia exists. Though certain historical per- 
sonages like Cgesar, Mohammed, Charles the Fifth, Peter the Great, 
and the Emperors Napoleon I. and III., were epileptic, their paroxysms 
were infrequent, and their intellectual qualities were characterized by 
unequal development and great defects, as well as by unusual vigor. 

The mild form of epilepsy is characterized by brief losses of con- 
sciousness (absentia epileptica). In the midst of conversation, or during 
any other protracted exercise, the patient suddenly becomes pale, ceases 
to speak or to act, stares vacantly for a few seconds, draws a deep sigh, or 
yawns, and then everything goes on naturally as before the paroxysm. 
In certain cases, during the period of unconsciousness, the patient is 
capable of movement, walks about, runs a short distance, utters profane 
or indecent ejaculations, or performs some strange and unusual act, to 
the great surprise of the bystanders, without any consciousness on his 
part, or any memory of the event after the paroxysm is concluded. 
Occasionally such a paroxysm is prolonged for many days, during 
which the patient lives a life of which there is no subsequent recollec- 
tion, unless during a future attack its memory is revived. Not unfre- 
quently the paroxysm assumes the form of simple vertigo, accompanied 
by slight and transient stupor. In many cases convulsions never occur, • 
but in others the mild and the severe forms of epilepsy are manifested 
by the same patient, or one form may be replaced by the other. 

The nature of the molecular changes within the brain upon which 
epilepsy is dependent is unknown, though the fact of their existence has 
been rendered unquestionable by experimental research. Vascular 
spasm and consequent cerebral anaemia have been suggested as the 
causes of loss of consciousness and of irritation of a hypothetical con- 
vulsive centre. Guinea-pigs can be rendered epileptic by rupture of the 
sciatic nerve, or by hemisection of the spinal cord, or by a blow upon 
the head. The disease is developed in the course of a few weeks, and 
its paroxysms may be excited by irritation of a particular spot upon the 
side of the neck below the ear. The disease thus acquired is trans- 
mitted to the offspring. Cortical epilepsy can be excited in dogs by 
electrical irritation of the cerebral cortex. 

Diagnosis. Epilepsy must be distinguished from the epileptiform 
convulsions that accompany many other diseases. Hystero- epilepsy is 
seldom accompanied by complete loss of consciousness ; it usually occurs 
among women, and is characterized by other hysterical symptoms. 
Simulated epilepsy may be recognized by the behavior of the pupils, 
which are not dilated and react to light ; while the thumb when forcibly 
extended is again flexed into the palm of the hand. 

Prognosis. Recovery is rarely observed, though the severity of the 
disease and the frequency of its paroxysms may be greatly diminished 
by appropriate treatment. 

Treatment. Epileptic mothers should not nurse their infant 
children, and the health of the growing child should be carefully invig- 
orated by every possible hygienic method. Alcohol, tea, and coffee 
must be excluded from the diet, and only digestible food should be 



900 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

allowed. The bowels must be evacuated every day. Moderately warm 
baths may be frequently enjoyed ; and all forms of excess must be 
avoided. It is always advisable to make a careful search for the ex- 
isteoce of causes of peripheral irritation. Phimosis should be removed 
by circumcision, and parasites of every kind must be mercilessly exter- 
minated. Removal of the ovaries has sometimes been practised, but 
its consequences are not sufficiently favorable to recommend the opera- 
tion. When the symptoms of cortical epilepsy clearly point to a definite 
lesion in the motor zone, the skull should be trephined, for the purpose 
of exploration and removal of any accessible cause of irritation. Periph- 
eral scars should also be incised, if they be sensitive and evidently 
connected with the occurrence of the epileptic paroxysm. Tubercular 
tendencies and diseases are benefited by the use of cod-liver oil. 
Anaemic patients should have iron and restoratives. Other constitu- 
tional diseases require appropriate treatment. 

Remedies innumerable have from time immemorial been prescribed 
for the relief of epilepsy. Almost every physician possesses some 
favorite specific which he considers particularly useful for the cure of 
the disease. Valerian, belladonna, nitrate of silver, and all the metals 
have been prescribed without any notable degree of success. The 
bromides alone possess any considerable or enduring virtue in the treat- 
ment of epilepsy. By many physicians a mixture of the different 
bromides is recommended, but the bromide of potassium is, of them all, 
the most efficient. It has the disadvantage of producing acne, or, if 
given in excess, of exciting maniacal symptoms or a condition of great 
prostration. Such abuse of the drug should never be practised. Under 
ordinary circumstances, bromide of sodium may be administered with 
more satisfactory results. It should be given in doses of fifteen grains 
and upward four times each day ; the last dose should be doubled and 
administered at bedtime. When combined with moderate doses of 
chloral hydrate a smaller quantity of the bromide is frequently suffi- 
cient, but this drug should not be administered for any length of time : 
the bromides alone may be safely exhibited for many years. When epi- 
leptic paroxysms are preceded by an aura of sufficient duration, they 
may be frequently averted by the inhalation of amyl nitrite. The same 
remedy may be employed with advantage during the status epilepticus. 

Eclampsia. 

Etiology. The term eclampsia is employed to signify those epi- 
leptiform paroxysms which occur as a consequence of irritation of the 
motor zone in the cerebral cortex. Such excitement is produced by 
uraemia, by lead poisoning, and by various diseases involving the 
meninges and the cerebral cortex. It inay occur during the course of 
pregnancy ; and it is a frequent incident among infants whose cerebral 
mechanism is still imperfectly developed, and who are consequently 
easily excited by all forms of peripheral irritation. It is not uncommon 
in such cases, during the course of infective diseases, and rickets, or 
whenever a feverish condition occurs, or when under the influence of 
violent mental excitement and emotion. 



FUNCTIONAL DISEASES OF THE BRAIN. 901 

Symptoms. The symptoms of an eclamptic attack correspond, in 
every respect, with those which are developed during a paroxysm of 
epilepsy. In young children they are frequently preceded by the oc- 
currence of restlessness, indigestion, and unquiet slumber during which 
the little patient laughs, moves uneasily, grinds his teeth, or wets his 
bed. The paroxysms are sometimes frequently repeated, developing a 
condition identical with the status epilepticus, and a fatal termination is 
not uncommon. 

Treatment. The general health of the patient should be carefully 
invigorated, and all causes of peripheral excitement and disease must be 
removed, so far as possible. During the occurrence of a paroxysm the 
child may be placed in a warm bath, while its head is cooled with cold 
water ; and the bowels should be relieved by an injection, or by a 
cathartic dose of calomel. Mustard plasters and other irritants are use- 
less, excepting in cases of great prostration. During the status epi- 
lepticus it may be necessary to resort to inhalations of amyl nitrite or 
chloroform. The bromides may be used after the paroxysm, as in cases 
of epilepsy. 

St. Vitus' Dance — Chorea. 

Etiology. Chorea is a frequent disease in early life, occurring 
during the period of second dentition, or about the age of puberty, or 
during early adult life. Among females it is twice as frequent as 
among males. It is usually observed among delicate, nervous chil- 
dren, who belong to neurotic and consumptive families. The pre- 
disposition may also be acquired by excessive mental activity, accom- 
panied by deficient nutrition, or any other cause of physical exhaustion 
or mental depression. The direct manifestation of the disease is fre- 
quently excited by violent emotions, by injuries, or by the presence of 
intestinal parasites or other causes of peripheral irritation. For the 
same reason it sometimes is developed during the course of pregnancy, 
usually during the period when the patient is subject to morning sick- 
ness and other evidences of nervous disturbance. It generally ceases 
after evacuation of the uterus, but it is not unfrequently fatal under 
such circumstances. 

Cardiac diseases are frequently associated with chorea, though it is 
doubtful whether they sustain the relation of cause and effect. In like 
manner infective diseases and rheumatism are sometimes followed by 
chorea. 

The disease is occasionally observed as a consequence of mimicry on 
the part of sportive companions who find themselves at last afflicted by 
the disease which they so successfully imitated. The disease is most 
frequently encountered during the cold and chilly months of the year, 
it sometimes appears to occur almost epidemically. 

Symptoms. Chorea frequently commences suddenly, but it is often 
preceded by a considerable period of general depression and disorder of 
the health. At length the irregular and involuntary movements of the 
extremities begin to attract attention ; the arms are in almost constant 
motion, pronation and supination rapidly succeed each other. The 
fingers are alternately flexed and extended, the shoulders are shrugged, 



902 DISEASES OF BRAIX AND CEREBRAL MEMBRANES. 

the head is irregularly twitched in various directions, the features are 
distorted by involuntary grimaces, respiration is often jerky and snuf- 
fling : what has been happily termed a universal muscular delirium is 
developed. The condition is frequently aggravated by mental excite- 
ment : sometimes, however, the reverse is apparent. During sleep the 
disorderly movements of the muscles are arrested, but they are renewed 
immediately after waking. In severe cases it becomes impossible for 
the patient to walk or to use his hands or to sit up. He must remain 
in bed. and unless care is taken he will often find himself upon the floor, 
and the skin may be excoriated by incessant friction. 

In such cases a hammock is often the best place for the comfort of 
the sufferer. 

In certain cases the choreic movements are restricted to one side 
(hemi-chorea). or they may involve a single limb. The left half of the 
body is most liable to the disease. 

Sensory disturbances are usually absent, though sometimes painful 
points exist over the spinous processes, or in the course of the periph- 
eral nerves. The electrical excitability of the nerves is usually un- 
changed, and the internal viscera remain unaffected. Pallor and 
emaciation are common events, and the mental faculties exhibit notable 
weakness. The patient appears silly, dull, forgetful, and irritable. 
Occasionally permanent mental nentis experienced. The pulse 

is usually enfeebled, but the bodily temperature remains without change 
in uncomplicated cases. 

Chorea is sometimes complicated by painful swelling of the joints and 
by rheumatism and cardiac diseases. Various evidences of muscular 
tveaJcness and hysterical disturbance are often observed. 

Pathological Anatomy. Chorea is a purely functional disease. 
The anatomical changes that have been sometimes described are quite 
accidental, and have no causal relation with the symptoms. 

Diagnosis. Choreic movements are sometimes caused by irritation 
of the motor z>:>n>: in the brain, as a consequence of inflammation, hem- 
orrhage, softening, tuberculous tumors, or parasites. In all such cases 
the. disease may be differentiated from chorea by the presence of other 
severe symptoms of local disease in the brain. Host- via is sometimes 
accompanied by hallucinations, disturbances of consciousness, and 
choreic movements. Tremor and paralysis agitans are distinguished 
by the regularity and moderation of the tremulous excursions. Mul- 
bro-spinal sclerosis exhibits muscular agitation only during 
voluntary movements. Athetosis is characterized by regular and per- 
sistent movements associated with other evidences of organic lesion. 
Post-hemiplegic <:horea is only observed in the paralyzed extremities 
after cerebral hemorrhage. 

PR' - 3. The duration of the disease varies from one to three 

months. Its course is sometimes arrested by intercurrent diseases, but 

it is frequently renewed after their termination. The prognosis is 

usually favorable, especially among children, though the occurrence of 

inate sleeplessness is an element of serious danger. 

Treatment. In the treatment of chorea it is desirable to eliminate 
every cause of peripheral irritation : especially should the aiimen- 



FUNCTIONAL DISEASES OF THE BRAIN. 903 

tary canal be carefully evacuated, and search be made for intestinal 
worms. Any specific or special disease must receive appropriate treat- 
ment. A warm bath every morning and evening is of considerable 
service. The galvanic current should be employed ; and if painful 
points can be discovered along the spinous processes or over the trunks 
of the peripheral nerves, the anode should be applied over them. For 
internal medication, Fowler's solution of arsenic may be given three 
times a day, commencing with three drops, and increasing the dose one 
drop each day until it reaches ten drops or more. Still better results 
may be obtained from the daily hypodermic injection of a single full 
dose of the solution. During the later stages of the disease benefit is 
sometimes derived from the use of strychnine ; and in very obstinate 
cases zinc sulphate may be given three times a day, commencing with 
one grain after each meal, and increasing by one grain each day until 
ten or twelve grains are taken at a time. In cases of sleeplessness it is 
necessary to administer chloral hydrate and alcoholic stimulants until 
sleep is procured. 

A form of chorea is sometimes observed among patients in middle 
life, occurring generation after generation among many members of the 
same family (hereditary chorea). The disease commences gradually, and 
extends until all parts of the body and extremities are involved. The 
bladder and rectum remain undisturbed, sensation is not affected, and 
the electrical reactions of the muscles are unchanged. After a time 
mental disturbance is observed, and suicidal inclinations are sometimes 
manifested. As the mind fails the body wastes, and finally death re- 
sults from exhaustion or from intercurrent disease. 

The terms prse- and post-hemiplegic chorea signify a form of chorea 
that is associated with hemiplegia as a consequence of cerebral hemor- 
rhage or other cerebral disease. The proB-liemiplegic form of the 
disease usualty commences several days before the apoplectic attack by 
which hemiplegia is produced, and the movements cease with the occur- 
rence of paralysis. The post-hemiplegic form of chorea, on the contrary, 
develops after the occurrence of paralysis, is frequently associated with 
muscular contracture in the paralyzed limbs, and continues usually 
through life. Sometimes the paralyzed side is also anaesthetic, a fact 
that points to the posterior and middle portion of the internal capsule 
as the seat of the disease. 

Athetosis. 

Athetosis is a symptom that is sometimes observed in cases of hemi- 
plegia, though it sometimes exists without paralysis in connection with 
epilepsy, idiocy, various forms of insanity, and other cerebral diseases. 
The fingers and toes manifest slow and irregular movements of flexion, 
extension, adduction, and abduction. (Fig. 168.) These movements 
are diminished, but do not entirely cease, during sleep. Muscular con- 
traction is sometimes present. Electrical reactions are unchanged. It 
is often possible to produce temporary suppression of the muscular 
.movements by firmly grasping the wrist or the ankle with the other 
hand, or by elevating the affected limb ; contractures then yield, and 



904 DISEASES OF BRAIX AND CEREBRAL MEMBRANES. 

Fig. IRS. 




Athetosis. (Church.) 

the movements cease, but are immediately renewed when pressure is 
removed. In certain cases the disease is undoubtedly identical with 
post-hemiplegic chorea. 

Shaking Palsy — Paralysis Agitans. 

Paralysis agitans is a disease of old age, characterized by muscular 
weakness and stiffness associated with a peculiar position of the body, 
and rigidity of the features, sometimes accompanied by compulsory move- 
ments, and almost always attended by tremor. 

Symptoms. Paralysis agitans sometimes begins suddenly, but is 
often gradually developed. The first characteristic symptom is pre- 
sented by tremor, involving the muscles of the fingers, and extending 
up the arm and to the lower limb : the opposite arm is then invaded, 
and finally the lower extremity on that side. Sometimes, however, the 
disease remains for a long time in one limb, or upon one side of the 
body. The muscles of the head and face are seldom affected. These 
tremors continue when the limbs are perfectly supported, and they 
either diminish or are not increased during voluntary movements. 
Mental agitation causes them to increase. They at first subside during 
sleep, but finally they persist at all times. The character of the tremor 
varies considerably. In the majority of cases the muscular excursions 
are but little greater than those which are observed as a consequence of 
alcoholism ; but not unfrefyuently they increase, and sometimes reach 
a very considerable magnitude, so that the chair upon which the patient 
sits, or the bed upon which he lies, is violently shaken by the muscular 
agitation. In certain cases, however, muscular tremor is entirely 
absent, and the disease can be recognized only by the peculiar stiffness 






FUNCTIONAL DISEASES OF THE BRAIN 



905 



Fig. 169. 



of the limbs and spine, the stolid rigidity of the features, and other 
characteristic symptoms of the disease. 

Still more valuable as a diagnostic symptom is the peculiar attitude 
of the patient and the position of his extrem- 
ities ; the extensor muscles become enfeebled, 
while the flexor muscles are rigid and slightly 
contracted. (Fig. 169.) The patient stands in 
a stooping position, with the head projecting 
forward, the knees and hips slightly flexed, 
the forearms flexed and pronated, the hands 
slightly flexed at the wrists, while the fingers 
and thumbs are placed in apposition as if 
holding a pen, or as if rolling a bullet 
between their tips. In certain cases the 
adductors of the thighs draw the limbs so 
close together that ulceration upon the inner 
surface of the knees is produced by their 
friction. In the act of walking the feet fre- 
quently assume the varus-equinus position, 
and the toes are flexed like the thumb and 
fingers. In certain cases the act of walking 
becomes difficult or impossible, in conse- 
quence of violent propulsive movements in 
the forward direction. If walking be possi- 
ble under such circumstances, the patient 
trips along as if about to fall forward. Occa- 
sionally a retropulsive movement is observed, 
and at each step the head and shoulders are 
drawn forcibly backward. Sometimes in the 
later stages of the disease natural locomotion 
becomes impossible and the patient can only 
move by plunging forward after being pro- 
perly placed with his face in the direction of 

the bed or couch toward which he must make Para i ysis ag itans. Rush Medi- 
his way. CAL College Clinic.) 

The temperature of the tremulous limbs 
is sometimes elevated ; the electrical reactions of the muscles and nerves, 
and the sensibility of the skin remain without notable change ; the 
tendinous reflexes are sometimes increased, and painful pressure- 
points are not uncommon upon the head, vertebral processes, and 
peripheral nerves. 

Remarkably characteristic is the expression of the countenance, 
which preserves a stern and solemn rigidity under all circumstances. 
Speech loses its expressive tones — becomes monotonous, and even stut- 
tering, when the muscles of articulation share in the universal tremor ; 
the lips usually remain partially open, and saliva often trickles from 
the corners of the mOuth. Perspiration is often increased, especially 
during the night-time ; and though the temperature of the body seldom 
rises, there is great complaint of heat accompanied by a disposition 
to throw off the bed-clothing. The uneasy sufferer cannot remain long 




DISEASES OF B R A I X AND CEREBRAL M E M B R A >V 

in one position, bur must be frequently moved, and groans with dial 
if his requests are unheeded. 

The mind usually 7. though in certain ease- 

termination of the disease is heralded by increasing apathy that may 
result in dementia. Under such circumstances the bladder and rectum 
may share in the approaching collapse. Like other chronic diseases 
of the central nervous organs, paralysis agitans is sometimes accom- 
panied by apopleetifor g for which no anatomical basis can be 
discovered. 

The duration of the dist \ ers many years, sometimes sting 

for more than a third of a century. 

Etiology and Pathological Anatomy. Xothing is known re- 
garding the nature and anatomical causes of paralysis agitans. The 
anatomical changes that have been sometimes observed are merely 
those which indicate senile degeneration, or are of accidental occur- 
rence. 

The exciting causes of the disease are generally the same that underlie 
the majority of nervous disease. ( . lold and injury, violent mental 
excitement, infective diseases, alcoholism, gout, debauchery, care, 
worry, together with the hereditary influences that operate in neurotic 
families, are the usual causes of paralysis agitans. 

Diagnosis. Paralysis agitans must be differentiated from simple 
w by the more extensive character of the muscular oscillations, 
and by the fact that ordinary tremor may be usually referred to old age 
or intoxication with alcohol, mercury, or lead. 3ful~ ' -<i>inaJ 

• I m '» lifters by the fact that its muscular oscillations are mani: 
only during voluntary movements, and are accompanied by nystagmus 
-canning speech. Chorea is characterized by the wider extent and 
greater irregularity of the muscular excursions. 

Prognosis and Treatment. The disease, though incurable, is not 
particularly dangerous to life. Its symptoms may be often temporarily 
relieved by the administration of hyoscyamine (grain ^r^ three times a 
The best results are obtained from the hypodermic injection of 
Fowler's solution of arsenic, of which from five to ten drops may be 
given each day. Orher remedies have been employed, but nothing 
affords anything better than temporary relief. 

Tremor. 

Symptoms. Tremor consists of rapidly successive brief muscular 
contractions, by which individual muscles, groups of muscles, or the 
entire locomotive apparatus are maintained in a si filiation. In 

the majority of cases the fingers and hand are first and principally in- 
volved. It may extend to other parts of the body, invading this or that 
muscular group, though the muscles of the eyes are rarely affected. 
Agitation ceases during sleep, and it may be diminished when the 
limbs are efficiently supported, or when a strong voluntary effort is 
exerted for its suppression. In certain cases it is increased by volun- 
tary movements. 

Etiolooy. Tn mor may be produced by violent emotion, by exees- 



FUNCTIONAL DISEASES OF THE BRAIN. 907 

sive muscular exertion, by the inordinate use of alcohol, opium, tea, 
coffee, and tobacco, or by poisoning with mercury, lead, and other 
metals. The symptom is frequently observed in connection with many 
forms of debility which are developed among nervous and anaemic per- 
sons, especially when they have been exhausted by debauchery, pro- 
longed lactation, or chronic wasting discharges. The symptom fre- 
quently occurs in extreme old age, and it is a common accompaniment 
of exophthalmic goitre. 

The anatomical basis of functional tremor is unknown. It undoubt- 
edly is of a character that interferes with the efficient efflux of tonic 
impulses from the brain and spinal cord to the muscles ; but the nature 
of the molecular changes by which this is conditioned is unknown. 

Treatment. Tremor often resists all therapeutic measures. So far 
as its exciting causes can be discovered, they should be removed. Good 
diet, restoratives, and tonics, together with change of air and occupa- 
tion, afford great relief. The judicious use of electricity and massage 
is very beneficial. Fowler's solution of arsenic, hypodermically, is an 
admirable restorative ; and temporary relief may be obtained from 
hyoscyamine (grain yj-g- three times a day). Valerian, strychnine, 
iron, quinine, and zinc phosphide are often beneficial. 

Vertigo. 

Vertigo is a symptom that is frequently associated with other func- 
tional disturbances of the brain. It is sometimes experienced during 
the daytime ; in other cases only during disturbed and interrupted sleep 
in the night-time. Sudden change of position is frequently followed 
by a brief paroxysm of dizziness, and it often is associated with various 
disordered conditions of the stomach. Sometimes the patient seems to 
whirl around, while in other cases external objects appear to be in a 
state of revolution. These subjective movements may be either hori- 
zontal or vertical. 

Vertigo is occasioned by a disturbance of the sense of bodily equilib- 
rium. This is frequently produced by different diseases involving vari- 
ous portions of the brain, and it is very commonly dependent upon a 
disordered condition of the different organs of special sense. Among 
old people it is frequently observed as a consequence of a diseased con- 
dition of the cerebral vessels, involving disorders in the vascular supply 
of the brain. The symptom, though by no means universally depend- 
ent upon the condition of the cerebellum, often occurs in an aggravated 
form when the different organs in the posterior fossa of the cranium are 
diseased. 

Vertigo is frequently occasioned by intestinal parasites, by chronic 
constipation, and by indigestion. It is sometimes observed at the time 
of menstruation, and in connection with the menopause. It may be 
associated with cardiac diseases and disorders of the blood that inter- 
fere with the cerebral circulation. The effect of alcohol and other nar- 
cotics in the production of vertigo is a matter of common observation. 
Paralysis of the muscles of the eyes is sometimes followed by vertigo 
dependent upon the defective coordination of the visual impressions by 



908 DISEASES OF BRAIX AND CEREBRAL MEMBRANES. 

which the sense of equilibrium is sustained. A notable form of vertigo 
is excited by diseases of the inner ear, or by the accumulation of wax 
upon the tympanum. When the labyrinth and semicircular canals are 

involved, vertigo occurs in connection with deafness and noises in the 
head (Meniere's disease). 

A symptom that is dependent upon so many and so widely different 
causes obviously cannot be subjected to any uniform method of treat- 
ment. Its cause must be ascertained and removed before a successful 
result can be reached. 

Catalepsy — Catalepsia. 

Catalepsy is an occasional symptom that may be observed in connec- 
tion with other functional disorders of the brain, viz.: hysteria, chorea, 
insanity, and intoxication with ether or chloroform. It sometimes occurs 
in the course of typhoid or intermittent fever, or as a symptom of in- 
flammation in the brain or its membranes. Associated with the phe- 
nomena of ecstasy and trance it has been frequently observed during 
periods of great emotional excitement. 

Catalepsy is characterized by paroxysms of muscular rigidity during 
which the limbs remain in any position that they have previously 
assumed, or in which they have been artificially placed. The muscles 

Fig. 17" 




Catalepsy. (Rush Medical College Clinic.) 



are not spasmodically contracted, and the joints can be readily flexed 
during passive movements, constituting what has been termed waxy 
flexibility. The patient is sometimes suddenly arrested during the act 
of voluntary movement, and the limbs retain their position, even though 
the attitude be constrained and unnatural, for a period of time varying 
from a few minutes to many hours or days. During this period '-"ii- 



FUNCTIONAL DISEASES OF THE BRAIN. 909 

sciousness may be more or less involved or completely suppressed; the 
stiffened limbs can be easily displaced, but retain their novel positions 
like the arms and legs of a jointed doll. (Fig. 170.) The electrical 
irritability of the muscles is somewhat increased. Those muscles of 
the body which are not under the control of the will do not exhibit 
any change of function — if food be introduced into the pharynx it is 
swallowed ; the reflexes are diminished, and, in severe cases, may dis- 
appear. The surface of the body becomes pale, and its temperature 
falls. 

In protracted cases there is danger of starvation, unless artificial 
feeding is enforced. 

The disease may be readily differentiated from simulated muscular 
rigidity by the graphic method. In genuine cases the sphygmograph 
when applied to the muscles registers a straight line, but when applied 
to the muscles of a simulator the line is broken by rapidly successive 
and extensive oscillatory movements. 

The treatment of catalepsy must be directed to the underlying disease 
or general conditions with which it is associated. 

Hysteria. 

Hysteria is a functional disease of the brain for which no apparent 
anatomical basis can be discovered. Hysterical symptoms, however, 
are frequently observed in association with numerous and widely differ- 
ing diseases, consequently they will vary according to the sphere in 
which they are manifested. 

Hysteria is more frequently observed among women, but it is not an 
uncommon occurrence in the masculine sex. Certain races are predis- 
posed to its manifestation, notably the Celtic and Asiatic races- It is 
usually experienced during the ten or fifteen years that follow the de- 
velopment of puberty, but magnificent examples of the disorder are not 
uncommon among young children and among women in middle life, or 
even later. It usually is developed in neurotic families in which for 
many generations nervous disorders have been common ; such hereditary 
influences are most frequently transmitted through the maternal line. 
The tendency frequently exists, however, not as a consequence of 
hereditary transmission, but as a result of congenital influences ; a fact 
that may be frequently recognized in consumptive families, or under the 
influence of other causes of debility among the parents of the future 
hysterical sufferer. Such a disposition may be still further aggravated 
by faulty education and by erroneous habits of life ; over-education, in- 
sufficient bodily exercise, emotional excitement, premature participation 
in the sights and experiences of city life, late hours, improper reading, 
and all forms of unnatural and unhealthy association, favor the develop- 
ment of hysterical symptoms. In such patients may be observed a 
fondess for emotional excitement and self-indulgence, without cultiva- 
tion of the power of self-control and self-denial. Slight physical dis- 
orders, fatigue, and emotional depression find in such individuals a sphere 
for the ready development of the most varied forms of hysteria. 

Though by no means always dependent, as its name would imply, 



010 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

upon uterine diseases, hysteria is, nevertheless, a not uncommon con- 
sequence of excitement of the sexual apparatus ; especially when such 
disease takes the form of slight and irritative disorders. The graver 
forms of disease are less frequently accompanied by hysterical symptoms. 
It is frequently a consequence of unsatisfied sexual appetite among 
the consorts of impotent men. 

Hysteria sometimes results in apparently healthy persons as a con- 
sequence of the terror and astonishment to which they have been sub- 
jected on witnessing an hysterical paroxysm. For this reason the 
disease sometimes appears in the form of a local epidemic in boarding 
schools, nunneries, and other societies of young people. 

Symptoms. Among the motor disorders produced by hysteria may 
be mentioned paralysis. This may involve single nerves, muscular 
groups, an entire extremity, or the whole body. Hysterical hemiplegia 
is frequently accompanied by hemianesthesia upon the same side, often 
involving the entire half of the head and body, though the limbs alone 
be involved in the paralysis. Such disturbances are frequently connected 
with other conspicuous symptoms of hysteria ; they may persist for a 
variable period of time, and may be finally terminated by a very sud- 
den and unexpected recovery. The left side of the body is affected 
more frequently than the right, and the arm more frequently than the 
leg. Muscular atrophy and change of the electrical reactions are not 
often observed, though the muscles often are weakened from disuse. 
The muscles of the face and eyes seldom experience paralysis, except- 
ing the upper lid, which not uncommonly droops (ptosis hysterica). 
Sometimes the muscles of deglutition are affected so that artificial feed- 
ing becomes necessary. Laryngeal paralysis is often experienced, and 
sometimes is followed by speedy recovery after the use of the tongue 
spatula, or after the application of electricity or some other unexpected 
form of excitation. 

In many cases hysterical contractures of the muscles may be observed 
in the limbs. They frequently follow the occurrence of an hysterical 
paroxysm, but are sometimes excited by trifling injuries. The arms 
are usually contractured in the position of flexion, while the lower ex- 
tremities remain extended. Such contractures do not disappear during 
sleep, though they may be relaxed under the influence of chloroform. 
The muscles become dwindled through disuse, and the joints are de- 
formed by chronic displacement of the affected limbs. In certain cases 
the tendinous reflexes are increased, and it is then probable that the 
lateral columns of the cord are sclerosed. Under unusual excitement such 
contractures and deformities may temporarily disappear, but they are 
liable to be reproduced after the subsidence of mental agitation. In 
many cases slight muscular tremor may be observed like that which 
exists under ordinary conditions of debility. 

Hysterical convulsions of a tonic or clonic character are not uncom- 
mon. Local spasms, such as affect the muscles of the face, are fre-. 
quently due to hysteria, and universal convulsions are often excited by 
comparatively trifling causes. They differ only from the convulsions 
of epilepsy by the preservation of consciousness and a certain amount 
of self-control that protects the patient against injury. Unlike the 



FUNCTIONAL DISEASES OF THE BRAIN. 911 

epileptic, the hysterical patient invariably chooses a comparatively safe 
and comfortable spot for the manifestation of convulsive phenomena. 
In certain cases, however, the symptoms assume great severity, and are 
protracted for a considerable period of time, constituting the so-called 
hystero-epilejptic paroxysm. The attack is preceded by an aura con- 
stituted by sensations as if something were moving in the stomach, or 
as if a ball were rising in the throat (oesophageal peristalsis). The 
patient appears delirious, experiences hallucinations and convulsions, 
during which consciousness may be completely abolished. These are 
followed by opisthotonus, by manifold twisting and wriggling of the 
body, accompanied by cataleptic positions, or rigidity of the limbs. 
These manifestations are succeeded by various attitudes and grimaces 
expressive of erotic or other emotion. Finally the paroxysm termi- 
nates more or less suddenly, and the patient recovers consciousness, but 
professes complete ignorance of what has occurred. In certain cases 
hysterical paroxysms may be excited by pressure upon certain sensitive 
spots that exist, apparently at random, upon different portions of the 
surface. Sometimes an attack may be speedily terminated by pressure 
upon these sensitive zones, one of which frequently exists a little above 
Poupart's ligament. This has been frequently referred to a sensitive 
condition of the neighboring ovary, but certainly, in the majority of 
cases, all the adjacent tissues and organs participate in the condition of 
hyperesthesia. 

Hystero-epilepsy is rarely attended with danger, but sometimes the 
status epilepticus is established, the temperature rises inordinately, and 
death occurs. 

In certain cases violent paroxysms of crying or of laughter occur, 
and cataleptic seizures are occasionally witnessed. 

Hysterical disturbances of sensation may exist, either in the form of 
exaltation (hyperesthesia), depression (anaesthesia), or perversion (par- 
esthesia). Anesthesia usually involves the back of the hand or the 
foot. It may occur in irregular patches which have no special relation 
with any particular nerve, or it may involve a whole extremity, or the 
entire body. Sometimes only particular forms of sensibility are affected, 
but frequently all the tissues are involved, and the skin may be wounded 
or punctured without any evidence of pain. The application of metallic 
plates or other irritants to the skin is sometimes followed by the trans- 
fer of anesthesia to the opposite side of the body, or by its complete 
disappearance. 

Hysterical neuralgia is frequently experienced ; many cases of coc- 
cygodynia and of irritable breast are due to this cause. Headache, 
and painful points upon the scalp (clavus hystericus), upon the spinous 
processes, joints, and other localities are not uncommon. ■ 

Vasomotor and secretory disturbances are sometimes manifested in 
the form of subcutaneous hemorrhages, or bleeding from the mucous 
membranes. Sometimes the tissues are rendered bloodless by a vaso- 
motor spasm, so that deep punctures are not followed by the appearance 
of blood. Copious and irregular perspiration is sometimes witnessed. 

The organ of vision is frequently disturbed by neuralgic pains in its 
vicinity, and by slight muscular spasms or contractures ; while the 



912 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

functions of the retina may be either exalted, depressed, or temporarily 
abolished. Light may be so intolerable that the patient must remain 
continually in a darkened room ; or the eye may be exposed to a 
brilliant illumination without perception of light. Visual hallucinations 
are frequent. Similar disturbances sometimes involve the organ of 
hearing, as well as the other special senses. The patient may ex- 
perience the most astonishing exaltation of these senses, or they may be 
temporarily abolished, or utterly perverted, so that disagreeable objects 
of sense become agreeable, and vice versa. Unnatural craving for 
inedible or undigestible articles, like chalk, slate pencils, etc., is some- 
times manifested. A not uncommon symptom consists in the accumula- 
tion of air that has been swallowed in the stomach, from which cavity 
it is subsequently eructated. Uncomfortable borborygmi are frequently 
experienced. Obstinate and uncontrollable vomiting frequently occurs, 
and sometimes the entire abdomen is enormously distended and ex- 
cessively sensitive (tympanites hysterica). Such cases have been mis- 
taken for genuine peritonitis, but they may be recognized by the absence 
of fever and by a great relief through deep pressure, or after an injection 
of assafoetida. Vomiting of blood, which sometimes occurs, may be a 
purely hysterical phenomenon, though search for the symptoms of 
gastric ulcer should always be carefully instituted in such cases. Some- 
times vasomotor and secretory disturbances in the abdomen are indicated 
by pulsation of the abdominal aorta, and by paroxysms of watery 
diarrhoea. 

Respiratory disturbance often takes the form of laryngeal spasm, or 
an asthmatic paroxysm, or a constant convulsive cough. Vicarious 
hemorrhages from the lungs indicate vasomotor disturbance. A peculiar 
anaesthesia of the fauces frequently exists, or it may be replaced by 
the opposite condition. Diaphragmatic spasm produces a violent hic- 
cough. Cardiac palpitation and neuralgia may frequently occur. The 
pulse is exceedingly variable, in correspondence with conditions of 
spasm or of paresis in the vascular walls. 

The condition of the urine exhibits great variation. Sometimes it is 
clear, watery, and copious, with low specific gravity. This is especially 
common after an hysterical paroxysm. In other cases the secretion of 
urine may be almost totally suppressed for days and weeks together, 
while urinous liquids are vomited from the stomach. In certain cases 
there is manifested a constant desire to urinate, while in others there is 
complete paralysis, necessitating the use of the catheter. In the uterine 
organs neuralgia may exist as an indication of hyperesthesia, which 
may be accompanied by spasmodic conditions of the muscular apparatus, 
constituting vaginismus. Menstrual disorders are not uncommon. 
Sometimes there is complete loss of sensibility in the vagina with total 
abolition of sexual appetite or sensation. The occurrence of pregnancy 
is often the occasion for the development of innumerable nervous dis- 
turbances. 

The appetites and emotions in like manner exhibit various alternating 
disturbances through exaltation of their normal function. Intolerable 
thirst and voracious hunger may be succeeded by absolute loathing of 



FUNCTIONAL DISEASES OF THE BRAIN. 913 

food and drink. In certain cases anomalous paroxysms of fever with 
incredible elevation of temperature have been observed. 

The moral and intellectual faculties frequently exhibit astonishing 
perversion. Self-consciousness and selfishness are greatly exalted, and 
the patient displays wonderful ingenuity in the devices by which she 
seeks to attract attention and to awaken sympathy. All sorts of dis- 
eases are simulated. Sometimes the patient learns to compress the bulb 
of the fever-thermometer, so as to give occasion for the impression that 
she is suffering with an intense fever, and sometimes she seeks to increase 
the deception by artificial acceleration of the respiration and of the 
pulse. Attempts at suicide are sometimes ostentatiously undertaken, 
but rarely attain to complete success. Uncontrollable fits of laughter 
and crying indicate the excitable condition of the emotional nature ; 
and sometimes it is impossible to draw the line between the manifesta- 
tions of hysteria and of genuine insanity. 

Manifold disorders of sleep are sometimes exhibited, in the form of 
somnambulism, ecstasy or trance. Sometimes the patient remains for 
months in a condition of stupor. In certain cases profound syncope 
may counterfeit the appearance of death itself. 

Loss of speech sometimes occurs, and the patient remains for weeks 
unable to utter an audible sound. The voice may be suddenly restored 
under the influence of sudden emotion or excitement. 

Hysteria is usually a chronic disease, and though interrupted by 
many remissions, and rarely fatal, it is usually a source of great misery 
through life. 

Treatment. The children of neurotic families, among whom a 
predisposition to hysteria may be reasonably anticipated, should be 
subjected to the most careful physical, mental, and moral training, so 
as to invigorate their bodies and to increase their power of self-control 
and consideration for others. Removal of the ovaries has been fre- 
quently practised for the relief of hysterical symptoms, but the opera- 
tion should never be performed unless the organs give unmistakable 
evidence of organic disease. Many cases are much benefited by abun- 
dant diet and massage, according to the rules adopted by Weir Mitchell. 
Hypnotism has been sometimes employed with temporary success. 
Conditions of excitement may be greatly tranquillized by long-continued 
warm baths. Electricity is frequently useful, especially in paralytic 
conditions, and when the muscles are in a state of contracture. The 
faradic brush is recommended in the treatment of anaesthetic condi- 
tions. Change of air and all forms of out-door life are desirable. 
Numerous remedies have been prescribed for internal use, but few of 
them effect any special modification of the disease. Amemia and local 
diseases accompanied by hysterical symptoms, of course, require appro- 
priate treatment, but simple uncomplicated hysteria is usually uncon- 
trollable by pharmacy. 

Neurasthenia. 

Neurasthenia is a condition of exhaustion which may be dependent 
upon functional weakness of the brain, of the spinal cord, of the vaso- 
motor nerves, or of the various ganglia and nerves that preside over the 

58 



914 DISEASES OF BRAIN AND CEREBRAL MEMBRANES. 

functions of the different viscera. The disease is most frequently 
encountered among slightly built and nervous persons, who have been 
inordinately overtaxed in the struggle for position and wealth in the 
highly organized and complicated development of modern society. The 
disease, like other nervous disorders, usually occurs among the mem- 
bers of neurotic families, especially among the children of debilitated 
parents. When on the basis of such hereditary predisposition a 
delicately organized youth launches at an early age upon the sea of 
excitement in a large city, and stimulates his appetites and passions in 
every possible way by the use of tea, coffee, tobacco, alcohol, and other 
narcotics, early disaster becomes inevitable. 

Symptoms. Cerebral neurasthenia is indicated by the symptoms of 
cerebral exhaustion. The spirits are depressed and easily excited, head- 
ache and insomnia frequently occur, or there may be an unusual dispo- 
sition to sleep. Mental exertion and the concentration of thought 
become difficult and fatiguing. Sleep is . unrefreshing and disturbed, 
and is attended by frequent disorders. The use of the eyes is often 
accompanied by pain and fatigue, and the sharpness of vision is fre- 
quently diminished. 

In many cases the patient experiences a disinclination to society : 
but others are uneasy when left alone. The patient shrinks from 
walking the streets and facing a crowd ; or, on the contrary, he may be 
overcome by irresistible terror if compelled to cross a wide and lonely 
space (agoraphobia). Fatigue and excessive perspiration follow slight 
exertion. Self-confidence disappears, and despondence takes its place. 

Spinal neurasthenia is indicated by immoderate fatigue after trifling 
exertion. The hands tremble, and copious perspiration breaks out 
after the slightest effort. Various perversions of cutaneous sensation, 
such as itching, burning, and numbness, are frequently experienced. 

Visceral neurasthenia is indicated by depression of the functions 
of the various organs. After slight exertion the voice is weakened and 
hoarse, or subjective dyspnoea may be experienced. Not unfrequently 
there is a sensation of palpitation at the heart, and the functions of 
digestion are easily disturbed. Sexual power is diminished, and its 
indulgence is attended with exhaustion. 

Prognosis. ■ Neurasthenia, though not dangerous to life, renders 
existence almost intolerable. Recovery may be reached through appro- 
priate treatment, but the disease is chronic and liable to relapses. 

Treatment. The treatment of neurasthenia must be guided by 
consideration of its special causes. The Weir Mitchell method is often 
of the greatest service. The patient should be removed from home, if 
possible, to a place remote from friends and acquaintances, and should 
be there kept in bed, and abundantly fed with milk and eggs, while 
massage and electricity are employed every day. This course of treat- 
ment should be continued for two or three weeks before the patient 
is allowed to leave the bed. After that time a gradually increasing 
amount of locomotion may be allowed. In many cases the treatment 
must be continued for a number of months. Horseback exercise, mas- 
sage, and gymnastic training, together with the use of electricity, should 
form an integral part of the daily life until health is completely restored. 



INDEX 



ABSCESS, nature of, 65 
of the liver, 388 

pulmonary, 484 

renal, 717 
Acne, cornea, 93 
Acquired immunity, 56 
Acromegaly, 850 
Actinomycosis, 111 
Acute infantile gastro-enteritis, 354 
Addison's disease. 728 

pigmentation in, 26 
Adenie,~599 
Adenoma, description of, 39 

varieties of, 39 
.Egophony, 497 
Aerobic bacteria, 54 
.Esthesiometer, 783 
Ageusia, 786 
Agoraphobia, 914 
Agraphia, 871 

Air cells of the lungs, dilatation of, 462 
Albumin, tests tor, 692 
Albuminuria, 692 
Alcoholic dementia, 684 

pseudo-tabes, 792 
Alcoholism, 681 

acute, 682 

chronic, 682 
Alexia, 871 
Allocheiria, 818 
Amimia, 871 
Amoeba, 92 

coli, 109 
Amyloid bodies, nature of, 24 

degeneration, 23 
Amyotrophic lateral sclerosis, 839 
Anaemia, causes of, 46 

cerebral, 874 

progressive pernicious, 601 

spinal, 810 
Anaerobic bacteria, 54 
Anaesthesia. 782 

dolorosa, 784 

gustatory, 786 

of the larynx, 437 

of the trigeminal nerve, 7S5 

olfactory, 785 
Analgesia, 783 
Anasarca, definition of, 47 
Anchylostomum duodenale, 82 
Aneurism, cardiac, 559 

caused by syphilis, 208 

cerebral, 891 

of the aorta, 585 
Angina pectoris, 566 
Angioma, description of, 36 

varieties of, 36. 37 
Anguillula intestinalis, 84 

stercoralis, 84 
Anosmia, 785 
Anthrax, 112 
Anti-toxiue of tetanus, 59 

production of, 56 
Aorta, acute inflammation of, 583 

aneurism of, 585 

chronic inflammation of. 583 

congenital narrowness of, 592 

constriction and occlusion of the isthmus 
of, 591 

diseases of, 583 

dissecting aneurism of, 592 



Aorta, embolism of, 592 

rupture of, 592 

thrombosis of, 593 
Aortic insufficiency, 529 

stenosis, 531 
Aphasia, 865, 871 

caused by syphilis, 208 
Apraxia, 871 

Apoplexia neonatorum, 862 
Apoplexy, pulmonory, 459, 471 

serous, 880 
Arthritis deformans, 666 
Artificial immunity, 56 
Ascaris lumbricoides, 77 
Ascites, 409 

adiposus, 410 

chylosus, 410 

definition of. 47 
Asiatic cholera, 256 
Aspergillus niger, 53 
Aspermatism, 748 
Asthma, bronchial, 453 

cardiac, 555 

excited by pharyngeal catarrh, 319 
Asymbolia, 871 
Ataxic paraplegia, 828 
Atelectasis, obstructive, 467 

pulmonum, 466 
Athetosis, 903 
Atrophy, cerebral, 893 

definition of, 22 

from disuse, 22 

from pressure, 22 

neurotic, 22 

senile, 22 

through partial starvation, 22 
Attenuation of contagia, 57 

of virus, 57 
Aura, in epilepsy, 897 
Auto-infection, 60 
Auto-intoxication, 60 
Axillary nerve, paralysis of, 765 
Azoospermia, 749 



BACILLUS typhosus, 115, 123, 126 
Bacteria, 50 
Bacterium coli, 119, 125 

of relapsing fever, 254 
Balantidium coli, 92 
Beri-beri, 789 

Bile pigmentation, nature of, 26 
Bilharzia, 91 
Biliarv calculi, 381 
colic, 382 

passages, cancer of, 380 
constriction of, 375 
occlusion of, 375 
Bilious fever, 97 
Bladder, abscess of, 741 
cancer of, 743 
catarrh of, 739 
diseases of, 739 
foreign bodies in, Til 

ffangrene of, 742 
lypenesthesia of, Tin 
paralysis of, 746 
spasm of, 746 
Blepharospasm. 771 
Blood, diseases of, 596 
in urine, test for, 696 










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INDEX. 



917 



Dissolution, nature of, 20 
Distoma haematobium, 91 

hepaticum, 90 

Ringeri, 91 
Dochmius, 82 
Dropsy, causes of, 47 

definition of, 45 

intermittent articular, 852 

peritoneal, 409 

varieties of, 47 
Drop wrist, 790 
Dupuytren's fingers, 669 
Dysentery, 105 

catarrhal, 108 

chronic, 108 

diphtheritic, 108 
Dyspepsia, nervous, 351 



RCLAMPSIA, 699, 900 
Ectocyst, 88 
Ectogenous bacteria, 52 
Ehrlich's test for the tubercle bacillus, 155 
Electrical reactions in paralysis of nerves, 756 
Embolism, cerebral, 885 

nature and causes of, 46 
Emphysema, alveolar, 462 

interlobular, 466 

substantial, 463 

vicarious. 463 
Empyema, 492 

necessitatis, 499 
Enchondroma, description of, 35 

varieties of, 35 
Endemic disease, 52. 
Endocardial diseases, 519 
Endocarditis, chronic, 526 

ulcerative, 519 

intermittent form of, 521 
typhoid form of, 521 

verrucose, 523 
Endocyst, 88 
Endogenous bacteria, 52 
Entophytes, 49 
Entozoa, 49 

Enuresis, nocturna, 745 
Epidemic cerebro-spinal meningitis, 216 

disease. 52 
Epilepsv, 895 

cortical, 865 

Jacksonian, or cortical, 896 
Epiphytes, 49 

Epithelioma, description of, 37 
Epizoa, 49 
Eructation, 349 
Erysipelas, 220 
Erythromelalgia, 851 
Etiology, definition of, 19 
European cholera, 256 
Excessive secretion of the gastric juice, 351 
Exophthalmic goitre, 568 
External capsule and claustrum, symptoms in 

diseases of, 871 
Exudation, 63 
Eyes and head, conjugated deviation of, 870 

centre for conjugated movements of, 865 



ITACIAL paralvsis, 753 

double, 758 
False croup, 426 
Farcv, 192 

buds, 192 
Fastigium of fever, 59 
Fatty degeneration, 22 
Fauces, acute catarrhal inflammation of, 315 

chronic catarrhal inflammation of 318 
Feeding, Weir Mitchell's method of, 351 
Fehling's test for saccharine urine, 648 
Fever, adynamic, 69 

asthenic, 69 

bilious, 97 

break-bone, 248 

canine typhoid, 120 

collapse in, 68 

continuous, 69 

definition of, 68 



Fever, double tertian, 94 

fastigium of, 59 

herpetic, 129 

hyperpyrexial, 68 

infective, 73 

inflammatory, 73 

intermittent, 69 

description of, 94 

malarial, 93 

moderate, 68 

neurotic, 73 

pernicious, 100 

principal signs of, 64 

quartan, 94 

quotidian, 94 

relapsing, 70, 251 

remittent, 69, 97 

scarlet. 236 

septic, 73 

severe, 68 

sthenic, 691 

subnormal, 68 

symptoms of, 70 

tertian, 94 

thermic; 877 

transient, 73 

typhoid. 115 

typho-malarial, 120 

typhus, 264 

yellow. 271 
Fibrinuria, 698 
\ Fibroma, description of, 32 
Fiji Islands, mortality of measles at, 235 
Filaria medinensis. 79 

sanguinis hominis, 80 
Fluke-worms, 90 
Fremitus, pleural, 494 
Functional disease, 19 
Fungi, 49 
Furuncle, 114 



GALL-BLADDER, dropsy of, 3S0 
suppuration of, 379 
Gall-stones, 381 
Galopprhythmus, 555 
Gangrene, dry, 21 

moist, 21 

nature of. 21 

of the lungs, 486 

symmetrical, 853 
Gastralgia, 349 
Gastric catarrh, acute, 329 
chronic, 331 

hemorrhage, 327 

juice, excessive secretion of, 351 
hyperaciditv of, 351 
tests for, 333 

parasites. 347 

ulcer, 336 
Gastromalacia, 346 
German measles, 228 
Giant cell, definition of, 27 
Glanders, 192 

bacillus, 192 

nodules of, 114 
Glaucosuria, 697 
Glioma, 889 

description of, 34 
Glomerulo-nephritis, 702 
Glosso-labio-laryngeal paralvsi>. - 1 
Glottis, oedema of, 429 

spasm of. 436 
Glycosuria, 648 

Gout, 657 

Gouty diathesis, 658 
Grand mal, 896 
Grippe, 135 
Growth, nature of, 20 
Guinea-worm, 79 
Gumma, 198 
Gummy tumor, 198 



H^EMATOIDIX. origin of, 25 
Hematuria, 694 
Baemoglobinuria, 697 

* 



918 



I X D E X 



Hemoglobinuria, paroxysmal. 

Haeniopericardiurc 582 

Haemophilia, 617 

Haemoplasmodium. 103 

Haemoptysis 

Haemorrhage i see Hemorrhage) 

Haemorrhoids. 367 

Haemothorax. 513 

Hair-worm. \ 

Hay fever, 424 

Health, definition of, 79 

officers, duties of, 300 
Heart, acute inflammation of. " " S 
atrophy of, 554 
chronic inflammation of. 558 
congenital valvular lesions of, 544 
dilatation of, 547 
fatty. 5-54 

hypertrophy of. 550 
intermittent. -566 
misplacement of, .561 
neuroses of. 562 
palpitation of. 562 
parasites of. 561 
rupture of, 560 
tumors of, 561 
Heat of inflammation. 64 
Hemianesthesia. 784 
Hemianopsia. 867 

Hemiatrophy, progressive facial. 849 
Hemi-chorea ._ 
Hemi crania. 848 
Hemiplegia, spinal, S12 
Hemorrhage, bronchial, 457 
bulb? 
cause e 

ebral 88C 
mediastinal, 515 
meningeal. 861 
pulmonary, 457 
spinal. 811 

meningeal, 803 
Hepatic veins, inflammation of, 403 

thrombus of. 403 
Hereditary ataxia. - - 
Herpetic fever. 129 
Heteropiasia. definition of. 29 
Hiccough, 773 
Hodgkin"s disease, 599 
Horn-pox. 282 
Hutchinson's teeth. 214 
Hvaline degeneration, 25 
Hydatid cyst, 88 

mole, nature of, S3 
Hydrarthrosis, definition of, 47 
Hydrocephalic cry, 187 
Hydrocephalus. 891 
definition of. 47 
Hydrornetra, definition of, 47 
Hydromyeli;. S2 
Hydronephrosis, 730 
definition of, 47 
Hydropericardium, 582 

definition of. 47 
Hvdroperitoneum. definition of. 47 
Hydrophobia, 291 
Hydrophobic tetanus, 153 
Hydro-pneumopericardium, 581 
Hydro-pneumotborax. 
Hydropsical degeneration. 22 
Hydroraehis. definition 
Hydrosalpinx, definition. 
Hydrotbionuria. 
Hydrothorax. 512 

definition of. 47 
Hyperacidity of the gastric jui 
Hyi>eraeniia,'cerebr 
definition of, 44 
spin,. 

varieties of. 44 
Hyperesthesia, gustator; 
of the la my 
olfactory. 78 
Hypeigenaa 78 
Byperosmia, v " 
Hyperplasia, definition 
Byperpyresi 



Hypertrophy, cerebral. - 

hemifacial 8S 

nature of Z7 

pseudo-muscular -" 
Hypoglossal nerve, paralysis : : 
Hvpoplasia. definition of. 21 
Hysteria, 909 
Hystero-epilepsy, 911 



ICTERUS. 375 
1 Ileus 



Lens, 366 

Immunity, acquired, 56 

against eontagia, 55 

artificial. 56 

natural. 56 
Impotence. 747 
Incubation, period of. 59 
Infantile paralysis. - \ 2 

acute cerebral. - 1 
Infarct, hemorrhag: : - ' 
Infective diseases, definition 1 1 

management of. 297 
Inflammation, 61 

course of. . 

definition of. 62 

heat of, 64 

interstitial. 67 

mediastinal, 514 

of csecum and vermiform appendix. 359 

of the bowels, acute catarrhal, 352 

of the nerve- 783 

parenchymatous 
influenza, 135 
Inoculated smallpox 288 
Intermittent fever, description of, 94 
Internal capsule, local symptoms in c:- 

of, 867 
Intestinal cancer. 361 

constriction, 364 

hemorrhage, 370 

mycosis. 113 

occlusion, 364 

tuberculosis. 179 

tumors, 363 
Intestines, diseases of. 3-52 
Intussusception, 363 
Invagination of the intestine 
Invasion, period of. 59 



JAPAN, absence of scarlet fever from, 241 
Jaundice, catarrhal 37^ 
Jenner, William, introduction of vaccination 
bv, 289 



KAKE 781 
Kidney, absence of. 726 
Kidnev. acute parenchvmatous inflammation 
. 701 
amyloid, 718 
cancer of. 722 
chronic parenchvmatous inflammation of. 

cirrhosis of. 711 
diffuse inflammation of. 701 
echinococcus of. 724 
embolic infarction of. 72 
fatty. 720 
gouty. 712 
horseshoe. 72 
iachaemia ( I 
large red " - 
large white. 702 
movable. 72S 
pig- back 

primary contracted. 711 
secondary contracted " 8 
senile inflammation of. 710 
superfluous 72 

suppurative inflammation of. 717 
tumors of. 724 
venous hyperemia of, 699 
Koch, discovery of cholera spirillum by. _ 
his method* of treating tuberculosi- 
- - 



INDEX 



919 



T ANDRY'S paralysis, 805 
L Laryngeal cough, 437 
Laryngeal neuroses, 433 

spasm in rickets, 624 

tuberculosis, 177 
Laryngismus, excited by pharyngeal catarrh, 
319 

stridulus, 426 
Laryngitis, 425 
Larynx, anaesthesia of, 437 

"catarrhal inflammation of, 425 

diseases of, 425 

hyperesthesia of, 437 

perichondrial inflammation of, 431 
Leptothrix buccalis, in the tonsils, 319 
Leucoplacia oris, 310 
Leukaemia, 596 
Life, 18 
Lipsemia, 632 

Lipoma, description of, 34 
Lipuria, 697 
Liver, abscess of, 388 

acute congestion of, 386 
hyperemia of, 386 
yellow atrophy of, 395 

adenoma of, 401 

amyloid, 398 

biliary cirrhosis of, 392 

cancer of, 399 

cirrhosis of, 390 

corset, 402 

diseases of, 375, 385 

fatty, 397 

degeneration of, 397 
infiltration of, 397 

granular, 391 

hernial protrusion of, 402 

malarial cirrhosis of, 393 

passive congestion of, 385 

passive hyperemia of, 385 

phosphorus-poisoning of, 393 

sarcoma of, 401 

syphilitic cirrhosis of, 392 

transportation of, 402 

venous congestion of, 385 

wandering, 401 

waxy, 398 
Living bodies, how formed, 18 
Loffler's bacillus, 146 
Lordosis, 767 

Louis XV., death of, from smallpox, 286 
Lungs, catarrhal inflammation of, 471 

oedema of, 470 

gangrene of, 486 

marasmic collapse of, 467 

splenification of, 469 
Lupus, in tuberculosis, 167 
Lutein pigmentation, nature of, 26 
Lymphangioma, description of, 37 
Lymph glands, inflammation of the tracheo- 
bronchial, 456 
Lymphoma, description of, 37 
Lympho-sarcoma, definition of, 37 
Lysis, in fever, 73 



MALARIAL cachexia, 101 
fever, 93 
Malignant pustule, 112 
Malleus humid us, 192 
Management of infective diseases, 297 
Mastodynia,779 
Measles, 230 

Median nerve, paralysis of, 764 
Mediastino-pericarditis, 581 
Mediastinum, diseases of, 514 
Medulla oblongata, acute inflammation of, 845 

diseases of, 840 

injuries and compression of, 846 
Melaena neonatorum, 372 
Melanaemia, 102, 608 
Melanine pigmentation, 25 
Melanosis, nature of, 25 
Melanuria, 697 
Meniere's disease, 908 
Meningitis, acute spinal, 800 
chronic spinal, 802 



Meningitis, epidemic cerebro-spinal, 216 
Meningocele, definition of, 47 
Mesenteric glands, diseases of, 404 
Metaplasia, definition of, 29 
Miasm, definition of, 48 
Micrococcus, 51 
Microphytes, 49 
Microsporon furfur, 164 
Migraine, 848 
Miliary carcinoma, 31 

tubercle, 158 

tuberculosis, 183 
Miserere, 366 
Mitral insufficiency, 532 

stenosis, 533 
Mole, hydatid, nature of, 33 
Molluscum contagiosum, 93 
Monoplegia, 812 

Montagu, Lady Mary Wortley, 288 
Morbilli, 230 
Morbus cseruleus, 544 

coxse senilis, 666 
Morphinism, 686 
Morphiomania, 686 
Morvan's disease, 821 
Mould, 49 
Mouth, aphthous disease of, 309 

catarrhal inflammation of, 307 

thrush in, 311 

ulceration of, 308 
Mucoid degeneration, 23 
Mucous polvp, definition of, 39 
Mumps, 226 
Muscles, acute multiple inflammation of. 857 

diseases of, 853 

ossification of, 856 

pseudo-hypertrophy of, 853 

true hypertrophy of, 856 
Musculo-cutaneous nerve, paralysis of, 765 
Myelitis, acute, 812 

central, 816 

chronic, 816 

circumscribed, 816 

disseminated or multiple, 816 

hyperplastica, 814 

transverse, 816 
Myocarditis, acute and chronic, 558 
Myoma, description of, 37 
Myo-sarcoma, description of, 37 
Myotonia, congenital, 809 
Myxcedema, 851 
Myxo-fibroma, 33 
Myxo-lipoma, 33 
Myxoma, description of, 33 
Myxo-sarcoma, 33 



NASAL catarrh, 421 
passages, diseases of, 421 
I Natural immunity, 56 
Necrosis, causes of, 21 

coagulative, 21 

definition of, 21 
Neoplasm, nature of, 27 
Nephritis, acute, 701 

catarrhal, 703 

chronic interstitial, 710 
parenchymatous, 707 

desquamative, 703 

suppurative, 717 
Nephrolithiasis, 734 
Nervous dyspepsia, 351 

vomiting, 347 
Neuralgia, cardiac, 566 

cervico-brachial, 778 

crural, 779 

intercostal, 778 

lumbo-abdominal. 779 

mammary, 779 

obturator, 779 

occipital, 777 

of joints, 782 

phrenic, 778 

sciatic, 780 

spermatic, 781 

trigeminal, 771 
Neurasthenia, 913 



920 



INDEX. 



Neuritis, 787 

migrans, 787 

multiple, 789 
Neuroma, description of, 43 
Neuroses, laryngeal, 433 
Nicotinism, 688 
Nictitation, 771 



OBESITY, 631 
(Edema, cerebral, 880 
(Edema, definition of, 45 

intermittent, angioneurotic, 852 

of the glottis, 429 
(Esophagus, cancer of, 322 

catarrhal inflammation of, 324 

constriction of, 319 

dilatation of, 323 

hemorrhage from, 326 

paralysis of, 326 

phlegmonous inflammation of, 325 

sacculation of, 323 

softening of, 326 

spasm of, 326 

spontaneous rupture of, 326 
Oidium albicans, 311 

Ophthalmoplegia, progressive nuclear, 844 
Oral parasites, 313 
Organic disease, 19 
Osteoma, description of, 35 

varieties of. 35 
Osteomalacia, 628 
Ovarian cyst, description of, 40 
Oxaluria, 655 

Oxygen, influence of, upon the growth of bac- 
teria, 53 
Oxyuris vermicularis, 79 
Ozsena, 423 



PACHYMENINGITIS, 798, 799 

hemorrhagic, 860 
Paget's disease of the nipple, 93 
Pancreas, diseases of, 404 
Pandemic disease, 53 

Papillary muscles, fatty degeneration of, 527 
Papilloma, definition of, 37, 38 
Parsesthesia, 784 

gustatory, 786 

olfactory, 786 
Parageusia, 786 
Paraglobulin, test for, 693 
Paralysis, acute ascending spinal, 805 
infantile, 832 

agitans, 904 

arsenical, 791 

Erb's, 766 

from alcohol, 792 

from carbon disulphide, 792 

from coal gas, 792 

from copper and zinc, 791 

from ergot, 792 

from phosphorus, 791 

Landry's, 805 

laryngeal, 433 

mercurial, 791 

of abdominal muscles, 767 

of axillary nerve, 765 

of crural nerve, 768 

of diaphragm, 767 

of erector spinse muscles, 767 

of facial nerve, 753 

of gluteal nerves, 769 

of hypoglossal nerve, 760 

of inward rotators of upper arm, 767 

of laryngeal muscles. 433 

of latissimus dorsi muscle, 767 

of median nerve, 764 

of musculo-cutaneous nerve, 765 

of obturator nerve, 768 

of outward rotators of upper arm, 767 

of pectoral muscles, 766 

of peroneal nerve, 769 

of radial nerve, 761 

of rhomboid and levator anguli scapulae 
muscles, 767 

of sciatic nerve, 769 



Paralysis of serratus muscle, 766 

of spinal accessory nerve, 760 

of tibial nerve, 769 

of ulnar nerve, 765 

progressive bulbar, 840 

psvchic spinal, 806 

reflex, 806 

saturnine, 790 

spastic spinal, 831 

spinal, of adults, 835 

toxic, 790 

vasomotor, 778 
Paramyoclonus multiplex, 810 
Para-nephritis, 726 
Paraplegia, 811 
Parasite. 49 
Paratyphlitis, 359 
Parenchymatous inflammation, 67 
Parosmia, 786 
Parotitis, 226 

secondary or symptomatic, 227 
Paroxysmal bradycardia, 566 

tachycardia, 562 
Passio-iliaca, 366 

Pasteur, experiments of, in rabies, 292, 295 
Pathological anatomy, definition of, 19 
Pathology, definition of, 19 
Peptone, test for, 693 
Pericardial adhesion, 580 
Pericarditis, 572 
Pericardium, diseases of, 572 

dropsy of, 582 
Perihepatitis, 387 
Perineuritis, 787 
Period of convalescence, 59 

of incubation, 59 

of invasion, 59 
Peripheral paralysis of nerves of lower ex- 
tremities, 768 

nerves, diseases of, 753 
Perisplenitis, 417 
Peritoneum, inflammation of, 404 
Peritonitis, 404 

chronic, 408 

fibrinosa, 405 

hemorrhagica, 405 

puerperal, 407 

purulenta, 405 

putrida, 405 

serosa, 405 
Perityphlitis, 359 
Pernicious fever, 100 
Pertussis, 244 
Petit mal, 896 
Phagocytosis, 60 
Pharyngeal tuberculosis, 178 
Pharynx, acute catarrhal inflammation of, 315 

chronic catarrhal inflammat'on of, 318 
Phosphatic diabetes, 655 
Phosphaturia, 655 
Phthisis enterica, 179 

laryngea, 177 

pharyngea, 178 

pulmonum, 161 

renalis, 181 
Pigeon-breast, 62^ 
Pigmentation with bile, 26 

with haemoglobin, 25 

with hseuiatoidin, 25 

with lutein, 26 

with melanine, 26 

with pus, 26 

with substances from the external world, 
26 
Pigmentary degeneration, 25 
Piles, 367 

Pityriasis versicolor, 164 
Plague, the, 268 
Plant, growth of, 17 
Plasmodium malaria?, 96, 103 
Pleura, cancer of, 514 

diseases of, 491 
Pleurisy, 491 

diaphragmatic, 498 

dry, 491 

encysted, 492 

fibrinous, 491 



INDEX 



921 



Pleurisy, hemorrhagic, 492 

ichorous, 492 

multilocular, 493 

putrid, 492 

suppurative, 492 

with effusion, 492 
neuritis humida, 491 

sicca, 491 
Plexiform neuroma, 43 
Pneumococcus, 474 
Pneumonia, bilious, 479 

catarrhal, 439, 471 

fibrinous, 474 

interstitial, 482 

lobar, 474 

lobular, 471 

malignant, 479 

secondary, 475 

typhoid, 479 
Pneumo-peritonitis, 407 
Pneumothorax, 507 

by Occlusion, 508 

patent, 508 

valvular, 508 
Poikilocytosis, 401 
Poliomyelitis acuta infantilis, 832 

Polysesthesia.783 

Polyp, mucous, definition of, 39 

Polvpus of the rectum, 363 

Polyuria, 653 

Pons "Varolii, local symptoms in diseases of, 

870 
Portal thrombosis, 402 

vein, suppuration of, 403 
Proctitis catarrhalis, 353 
Professional cramp, 806 
Prognosis, definition of, 19 
Progressive facial hemiatrophy, 849 

locomotor ataxia, 826 

muscular atrophy, juvenile, 855 
spinal, 835 
ossification, 856 
Propeptone, test for, 693 
Proscolex, 85 
Prostatorrhoea, 750 
Protoplasm, nature of, 17 
Protozoa, 92 
Psammoma, 889 

nature of, 34 
Pseudo-leukaemia, 599 
Pseudo-tabes, 643 
Pseudo-tuberculosis, 158 
Psychical blindness, 867 
Ptomaines, origin of, 56 
Ptosis hysterica, 910 
Ptyalism, 313 
Pulmonary apoplexy, 471 

collapse, 466 

consumntion, 161 

hypostasis, 469 

valve, insufficiency of, 535 
stenosis of, 535 
Pulsus paradoxus, 581 
Pupil, Argyll-Robertson's, 829 
Purpura, hemorrhagic, 611 

rheumatic, 610 

simple, 609 
Purulent gastritis, 335 

pigmentation, nature of, 26 
Pus, ichorous, 66 

laudable. 65 

nature of, 65 

sanious. 66 
Pyelitis, 732 
Pyelo-nephritis, 732 
Pylephlebitis, 403, 413 
Pylethrombosis, 402 
Pyloric incontinence, 345 
Pyo-nephritis, 732 

Pyo-pneumothorax, subphrenic, 511 
Pyothorax, 492 



QUARANTINE, 299 
Quartan fever, 94 
Quotidian fever, 94 



RABIES, 291 
Radial nerve, paralysis of, 761 
Raynaud's disease, 853 
Reaction of degeneration, electrical, 
Receptivity, nature of, 54 
Relapsing fever, 251 
Remittent fever, 97 
Renal diseases, 692 

sand, 735 
Rheumatic gout, 666 
Rheumatism, acute, 672 

cerebral, 673 

chronic, 677 

masked, 673 

muscular, 679 

nodular, 666 
Rheumatoid arthritis, 666 
Rhinitis, 421 
Rhinoliths, 422 
Rhinorrhoea, 422 
Rickets, 621 
Roseola, 234, 240 
Rot, the, 91 
Rotheln, 228 
Rubeola, 228 
Rumination, 349 



PACCHARINE diabetes, 640 

n Sago spleen, 418 

St. Vitus's dance, 901 

Salivary secretion, diminution of, 314 

Salivation, 313 

Saltatory spasm, 831 

Sandwich Islands, mortality of measles at, 235 

Saprophyte, 49 

Sarcina. 52 

ventriculi, 332 
Sarcoma, description of, 35 

varieties of, 35 
Scar, formation of, 66 
Scarlatina, 236 
Scarlet fever, 236 
Sciatica, 780 
Sclerosis, 67 

multiple cerebro-spinal, 817 
Scolex, 85 
Scoliosis, 767 
Scrofula, 159 
Scrofulous diathesis, 159 
Scurvy, 613 

Secondary infection, 60 
Sensation, common, 782 

tactile, 782 
Serratus muscle, paralysis of, 766 
Sick headache, 351 
Signs, physical, definition of, 19 
Singultus, 773 
Skin-grafting, 67 
Smallpox, 276 
Sordes, 71 
Spasm of diaphragm, 773, 774 

of facial nerve, 769 

of glottis, 436 

of hypoglossal muscles, 771 

of laryngeal muscles, 437 

of levator anguli scapulae muscle, 773 

of muscles controlled by the acces 
nerve, 771 
in the lower extremities, 774 
in the neck, shoulder, and arm, 77: 
of mastication, 771 

of rhomboid muscle, 773 

of splenius capitis muscle, 773 

vasomotor, 778 
Spermatorrhoea, 749 
Sphacelus, 21 
Spinal accessory nerve, paralysis of, 7150 

cord, acuteinflammation of, 812 
anatomy of, 795 
cavities in, 820 
chronic inflammation of, 816 
compression of, 823 
concussion of, 821 
effect of local lesions of, 797, 798 
embolic and thrombotic softening of, 817 



922 



INDEX. 



Spinal cord, functional diseases of, 804 
injuries of, 824 
multiple sclerosis of, 817 
physiology of, 796 
sclerosis of, 814 

secondary degeneration of, 83S 
systematized diseases of, 826 
tumors of, 820 
unsystematized diseases of, 810 

dura mater, external inflammation of, 
798 
internal inflammation of, 799 

hemiplegia, 825 

irritation, 804 

nerves, functions of, 797 
Spirillum, 52 
Spiro-bacterium, 52 
Spirochete Obermeieri, 254 
Spleen, acute enlargement of, 413 

amyloid degeneration of, 418 

cancer of, 418 

chronic enlargement of. 415 

diseases of, 413 

embolic infarction of, 416 

inflammation of, 417 

rupture of, 419 

transposition of, 419 

wandering, 419 
Splenic abscess, 417 
Splenitis, 417 
Sporocysts, 90 
Sporozoa, 92 
Staphylococcus, 51 
Stenosis of the heart, 537 
Stomach, cancer of, 340 

dilatation of, 343 

diseases of, 327 

functional diseases of, 347 

polypous tumors of, 343 

rupture of, 347 - 

softening of, 346 

toxic inflammation of, 336 
Stomatitis aphthosa, 309 
Strangury, 706 
Streptococcus, 51 
Strongylus gigas, 84 
Succussion sound, in pleurisy, 509 
Sunstroke, 877 
Suppuration, 65 

Supra-renal capsules, diseases of, 728 
Sympathetic nerve, irritation of the cervical,, 
847 

paralysis of the cervical, 847 

nerves, diseases of, 847 
Symptoms, definition of the term, 19 
Syphilis, 197 

bronchial, 203 

hereditary, 212 

laryngeal, 201 

of alimentary eanal, 204 

of liver, 205 

of nose, 200 

of peripheral nerves, 212 

of sexual organs, 206 

of spinal cord, 211 

of spleen, 206 

of vascular organs, 207 

police regulation of, 304 

pulmonary, 203 

renal, 206 
Syringomyelia, 820 



rfABES dorsalis, 826 
1 Tachycardia, 562 



Tactile sensation, its varieties, 782 
Tajnia echinococcus, 88 

mediocanellata, 87 

solium, 84 
Tapeworms. 84 
Taste, disorders of, 786 
Temperature, in hysteria, 91 3 
Teratoma, description of, 43 
Tertian fever, 94 
Tests for the gastric juice, 333 
Tetanus. 151 



Tetanus, anti-toxine of, 59 

bacillus, 151 

cerebral, 153 

hydrophobic, 153 

idiopathic, 152 

local, 153 
Tetany, 807 
Tetrageni, 52 

bacillus, 52 
Thalamus opticus, local symptoms in diseases 

of, 871 
Thomsen's disease, 809 
Thrombosis, cardiac, 545 

cerebral, 885 

nature and causes of, 46 
Thrush, 49, 311 
Thymus gland, abscess of, 517 
diseases of, 517 
hemorrhage into, 517 
hypertrophy of, 517 
tumors of, 517 
Tophi, 660 
Tormina, 105 

Toxic inflammation of the stomach, 336 
Trachea, catarrhal inflammation of, 438 

diseases of, 438 
Traumatic neurosis, 822 
Treatment, nature of, 19 
Trematodes, 90 
Tremor, 906 
Trichina, 81 

Trichocephalus dispar, 82 
Trichomonas intestinalis, 92 

vaginalis, 92 
Tricuspid valve, insufficiency of, 536 

stenosis of, 537 
Trigeminal nerve, paralvsis of motor portion 

of, 759 
Trimus, 152 

Trousseau, on diphtheria, 147 
Tubercle bacillus, 155 

forms of, 157 

miliary, 158 
Tubercular peritonitis, 191 

pericarditis, 190 

pleurisy, 189 

meningitis, 186 
Tuberculin, 176 
Tuberculosis, 154 

attempt to suppress, in Naples, 304 

intestinal, 179 

laryngeal, 177 

meningeal, 186 

miliary, 183 

pericardial, 190 

peritoneal, 191 

pharyngeal, 178 

pleuritic, 189 

pulmonary, 161 

renal, 181 

urinary, 181 

Weir Mitchell's method in. 174 
Tumor, benign, 31 

cartilaginous, 35 

definition of the term, 29 

malignant, 31 

mixed, 30 

prototypical, 30 

secondary. 31 

typical, 29 
Tumors, bulbar, 845 

cerebral, 888 

mediastinal, 515 

of the spinal meninges, 803 
Tvmpauites hysterica, 912 
Typhlitis. 359 
Typhoid fever, 115 
Typho-malarial fever, 120 
Typho-toxine, 124 
Typhus fever, 264 



LNAR nerve, paralysis of, 765 
I'pper extremity, associated paralysis of, 

765 



76E 
Uraemia, 706, 714 



INDEX 



923 



VACCINATION, 288 
introduction of, by William Jenner, 289 
Vaginismus, 912 
Varicella, 276 
Variola, 278 
Vascular nsevus, 36 
Vegetations, endocardial, 523 
Vertigo, 907 
Virus, attenuation of, 57 

nature of, 56 
Vital force, 17, 18 
Volvulus, 366 



WARTS, nature of, 38 
Warty growths, cause of, 30 
Warty smallpox, 282 
Weir Mitchell's method of feeding, 351 



Whooping-cough, 244 

Word-blindness, 867 

Worms, cestoid, 84 

intestinal, 77 

lumbricoid, 77 

nematoid, 77 

Writer's cramp, 806 



VANTHOPSIA, 377 

YEAST plant, 50 
Yellow fever, 271 



yOOGLEA, 51 



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TICS— By L. F. Warner, M.D., Attending 
Physician, St. Bartholomew's Dispensary, N.Y. 

PRACTICE OF MEDICINE— By Edwin T. 
Dot hleday, M.D., Member N. Y. Pathological 
Society, and J. D. Nagel, M. D , Member 
N. Y. County Medical Association. 



SURGERY (Double Number)— By R. A. Sands 
M.D., Assistant Demonstrator of Anatomy 
College of Physicians and Surgeons, N. Y. 
For special circular with full information and specimen pages address the publishers 



DISEASES OF THE SKIN— By Charles C. 

Ransom, M.D, Assistant Dermatologist, Yan- 

derbilt Clinic, New York. 
DISEASES OF THE THROAT, NOSE, 

EYE AND EAR — Bv Fr.-nk E. Miller, 
M.D., Throat Surgeon, Vanderbilt Clinic, New 
York, assisted by James P. MacEvoy, M.D., 
Throat Surgeon, Bellevue Hospital, Out- 
Patient Department, N*-w York, and John. 
Bates, M. D., Assistant Surgeon, Manhattan 
Eye and Ear Hospital, New York. 

OBSTETRICS — By Charles W. Hayt, M.D., 
House Physician, Nursery and Children's 
Hospital, New York. 

GYNECOLOGY— By G. W. Bratenahl, M. D., 
Assistant in Gynecology, Vanderbilt Clinic, 
New York, assisted by Sinclair Tousey, M. D., 
Assistant Surgeon, Out-Patient Department, 
Roosevelt Hospital, New York. 

DISEASES OF CHILDREN-By C.A.Rhodes, 
M. D., Instructor in Diseases of Children, New 
York Pest-Graduate Medical College. 



THE MEDICAL NEWS PHYSICIANS' LEDGEB. 

Containing 300 pages of fine linen " ledger " paper, ruled so that all the accounts of a 
large practice may be conveniently kept in it, either by single or double entry, for a long 
period. Strongly bound in leather, with cloth sides, and with a patent flexible back, 
which permits it to lie perfectly flat when opened at any place. Price, $4.00. 



4 Lea Brothers & Co.'s Publications — Dictionaries. 

THE STANDARD. 

THE 

Uktioukl UlzmAi DunrionaKY 

INCLUDING 

English, French, German, Italian and Latin Technical Terms used in Medicine and 
the Collateral Sciences, and a Series of Tables of Useful Data. 

BY 

John $. Billing*, JJ.D., LL.D., Ediq. and HMV, D.d.L, Opq. 

Member of the National Academy of Sciences, Surgeon U. S. A., etc. 
WITH THE COLLABORATION OF 

Pbof. W. O. ATWATER. JAMES M. FLINT, M. D., WASHINGTON MATTHEWS, M.D., 

FRANK BAKER, M. D., J. H. KIDDER, M. D., C. S. MINOT, M. D. 

S. M. BURNETT, M. D., WILLIAM LEE, M.D., H. C. YARROW, M. D., 

W. T. COUNCILMAN, M. D., R. LORINI, M.D., 

In two very handsome royal octavo volumes containing 1574 pages, 
with two colored plates. 

Per Volume— Cloth, $6; ZeatJier, $7; Half Morocco, Marbled Edges, $8.50. For Sale 
by Subscription only. Specimen pages on application. Address the Publishers. 



Its scope is one which will at once satisfy the 
student and meet all the requirements of the med- 
ical practitioner. Clear and comprehensive defi- 
nitions of words should form the prime feature of 
any dictionary, and in this one the chief aim 
seems to be to give the exact signification and the 
different meanings of terms in use in medicine 
and the collateral sciences in language as terse as 
is compatible with lucidity. The work is remark- 
able, too, for its fulness. The enumerations and 
subdivisions under each word heading are strik- 
ingly complete, as regards alike the English tongue 
and the languages chiefly employed by ancient 



continental languages which are richest in med- 
ical literature. To add to its usefulness as a work 
of reference some valuable tables are given. 
Another feature of the work is the accuracy of its 
definitions, all of which have been checked by 
comparison with many other standard works in 
th6 different languages it deals with. Apart from 
the boundless stores of information which may be 
gained by the study of a good dictionary, one is 
enabled by the work under notice to read intelli- 
gently any technical treatise in any of the four 
chief modern languages. There cannot be two 
opinions as to the great value and usefulness of 



.and modern science. It is impossible to do justice | this dictionary as a book of ready reference for all 
to the dictionary by any casual illustration. It j sorts and conditions of medical men. So far as 
presents to the English reader a thoroughly we have been able to see, no subject has been 
scientific mode of acquiring a rich vocabulary and omitted, and in respect of completeness it will be 
offers an accurate and ready means of reference in found distinctly superior to any medical lexicon 
•consulting works in any of the three modern [ yet published. — The London Lancet, April 5, 1890. 



MAKTSKORinE, HENBY, A. M., M. !>., LL. D., 

Lately Professor of Hygiene in the University of Pennsi/lvania. 

A Conspectus of the Medical Sciences ; Containing Handbooks on Anatomy. 
Physiology, Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics, 
Second edition, thoroughly revised and greatly improved. In one large royal 12mo. 
volume of 1028 pages, with 477 illustrations. Cloth, $4.25 ; leather, $5.00. 



LUDLOW, J. L., M. &., 

Consulting Physician to the Philadelphia Hospital, etc. 

A Manual Of Examinations upon Anatomy, Physiology, Surgery, Practice of 
Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy and Therapeutics. To which 
is added a Medical Formulary. Third edition, thoroughly revised, and greatly enlarged. In 
one 12mo. volume of 816 pages, with 370 illustrations. Cloth, $3.25 ; leather, $3.75. 

The arrangement of this volume in the form of question and answer renders it espe- 
cially suitable for the office examination of students, and for those preparing for graduation. 



HOBLYN, RICBLARD Z>., M. JD. 

A Dictionary of the Terms Used in Medicine and the Collateral 
Sciences. Revised, with numerous additions, by Isaac Hays, M. D., late editor of 
The American Journal of the Medical Sciences. In one large royal 12mo. volume of 520 
double-columned pages. Cloth, $1.50 ; leather, $2.00. 

It is the best book of definitions we have, and ought always to be upon the student's table.— Southern 
Medical and SurgtcM Journal. 



Lea Brothers & Co.'s Publications — Anatomy, Dictionary. 



GJRAY, HENRY, F. JR. 8., 

Lecturer on Anatomy at St. George's Hospital, London. 

Anatomy, Descriptive and Surgical. Edited by T. Pickering Pick, 
F. R. C. S., Surgeon to and Lecturei on Anatomy at St. George's Hospital, London, 
Examiner in Anatomy, Royal College of Surgeons of England. A new American from 
the eleventh enlarged and improved London edition, thoroughly revised and re-edited 
by William W. Keen, M. D., Professor oi Surgery in the Jefferson Medical College of 
Philadelphia. To which is added the second American from the latest English edition of 
Landmarks, Medical and Surgical, by Luther Holden, F. R. C. S. In one imperial 
octavo volume of 1098 pages, with 685 large and elaborate engravings on wood. Price of 
edition in black: Cloth, $6; leather, $7; half Russia, $7.50. Price of edition in colors 
(see below): Cloth, $7.25; leather, $8.25; half Russia, $8.75. 

This work covers a more extended range of subjects than is customary in the ordinary 
text-books, giving not only the details necessary for the student, but also the application of 
those details to the practice of medicine and surgery. It thus forms both a guide for the 
learner and an admirable work of reference for the active practitioner. The engravings 
form a special feature in the work, many of them being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in 
place of figures of reference with descriptions at the foot. In this edition a new departure 
has been taken by the issue of the work with the arteries, veins and nerves distinguished 
by different colors. The engravings thus form a complete and splendid series, which will 
greatly assist the student in forming a clear idea of Anatomy, and will also serve to refresh 
the memory of those who may find in the exigencies of practice the necessity of recall- 
ing the details of the dissecting-room. Combining, as it does, a complete Atlas of 
Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, 
the work will be found of great service to all physicians who receive students in their 
offices, relieving both preceptor and pupil of much labor in laying the groundwork of a 
thorough medical education. 

For the convenience of those who prefer not to pay the slight increase in cost necessi- 
tated by the use of colors, the volume is published also in black alone, and maintained 
in this style at the price of former editions, notwithstanding its largely increased size. 

Landmarks, Medical and Surgical, by the distinguished Anatomist, Mr. Luther Holden, 
has been appended to the present edition as it was to the previous one. This work gives 
in a clear, condensed and systematic way all the information by which the practitioner can 
determine from the external surface of the body the position of internal parts. Thus 
complete, the work will furnish all the assistance that can be rendered by type and 
illustration in anatomical study. 

books. The work is published with black and 
colored plates. It is a marvel of book-making. — 
American Practitioner and News, Jan. 21, 1888. 

Gray's Anatomy is the most magnificent work 
upon anatomy which has ever been published in 
the English or any other language.— Cincinnati 
Medical News, Nov. 1887. 

As the book now goes to the purchaser he is re- 
ceiving the best work on anatomy that is published 
in any language. — Virginia Med. Monthly, Dec. 1887. 

Gray's standard Anatomy has been and will be 
for years the text-book for students. The book 
needs only to be examined to be perfectly under- 
stood. — Medical Press of Western New York, Jan. 
1888. 



The most popular work on anatomy ever written. 
It is sufficient to say of it that this edition, thanks 
to its American editor, surpasses all other edi- 
tions — Jour, of the Amer. Med. Ass'n, Dec. 31, 1887. 

A work which for more than twenty years has 
had the lead of all other text-books on anatomy 
throughout the civilized world comes to hand in 
such beauty of execution and accuracy of text 
and illustration as more than to make good the 
large promise of the prospectus. It would be in- 
deed difficult to name a feature wherein the pres- 
ent American edition of Gray could be mended 
or bettered, and it needs no prophet to see that 
the royal work is destined for many years to come 
to hold the first place among anatomical text- 



Also for sale separate — 
HOLDBIT, LUTHER, F. JR. C. 8., 

Surgeon to St. Bartholomew's and the Foundling Hospitals, London. 

Landmarks, Medical and Surgical. Second American from the latest revised 
English edition, with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in 
the Penna. Academy of Fine Arts. In one 12mo. volume of 148 pages. Cloth, $1.00. 



&TJNGLI80N, JROBLEY, M.JD., 

Late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia, 

MEDICAL LEXICON; A Dictionary of Medical Science : Containing 
a concise Explanation of the various Subjects and Terms of Anatomy, Physiology, Pathol- 
ogy, Hygiene, Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical Juris- 
prudence and Dentistry, Notices of Climate and of Mineral Waters, Formulae for Officinal, 
Empirical and Dietetic Preparations. With the Accentuation and Etymology of the Terms, 
and the French and other Synonymes, so as to constitute a French as well as an English 
Medical Lexicon. Edited by Richard J. Dunglison, M. D. In one very large and 
handsome royal octavo volume of 1139 pages. Cloth, $6.50; leather, raised bands, $7.50; 
very handsome half Russia, raised bands, $8.00. 

It has the rare merit that it certainly has no rival in the English language for accuracy 
and extent of references.— London Medical Gazette. 



6 Lea Brothers & Co.'s Publications — Anatomy. 

ALLEN, SABBISON, M. L>., 

Professor of Physiology in the University of Pennsylvania. 

A System of Human Anatomy, Including Its Medical and Surgical 
Relations. For the use of Practitioners and Students of Medicine. With an Intro- 
ductory Section on Histology. By E. O. Shakespeare, M. D., Ophthalmologist to 
the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 
illustrations on 109 full page lithographic plates, many of which are in colors, and 241 
engravings in the text. In six Sections, each in a portfolio. Price per Section, $3.50 ; 
also bound in one volume, cloth, $23.00 ; very handsome half Russia, raised bands and 
open back, $25.00. For sale by subscription only. Apply to the Publishers. 

It is to be considered a study of applied anatomy j care, and are simply superb. There is as much 
in its widest sense — a systematic presentation of of practical application of anatomical points to 
such anatomical facts as can be applied to the the every-day wants of the medical clinician as 
practice of medicine as well as of surgery. Our to those of the operating surgeon. In fact, few 
author is concise, accurate and practical in his general practitioners will read the work without a 
statements, and succeeds admirably in infusing feeling of surprised gratification that so many 
an interest into the study of what is generally con- points, concerning which they may never have 
sidered a dry subject. The department of Histol- . thought before are so well presented for their con- 
ogy is treated in a masterly manner, and the sideration. It is a work which is destined to be 
ground is travelled over by one thoroughly famil- the best of its kind in any language.— Medical 
lar with it. The illustrations are made with great , Record, Nov. 25, 1882. 



CLARKE, W. B., F.B. C.S. & LO CKWOOD, €. B., F.B. C.S. 

Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. 
The Dissector's Manual. In one pocket-size 12mo. volume of 396 pages, with 
49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 

Messrs.Clarke and Lockwood have written a book ' intimate association with students could have 
that can hardly be rivalled as a practical aid to the given. With such a guide as this, accompanied 
dissector. Their purpose, which is " how to de- by so attractive a commentary as Treves' Surgical 
scribe the best way to display the anatomical Applied Anatomy (same series), no student could 
structure," has been fully attained. They excel in fail to be deeply and absorbingly interested in the 
a lucidity of demonstration and graphic terseness study of anatomy. — JYetc Orleans Medical and Sur- 
of expression, which only a long training and | gical Journal, April, 1884. 

HIBST, BABTONC, M.D., & JPIEBSOL, GEO. A., M.D. 

Professor of Obstetrics in the University Professor of Anatomy and Embryology in 

of Pennsylvania. the University of Pennsylvania. 

Human Monstrosities. Magnificent folio, containing about 150 pages of text, 
illustrated with engravings, and 39 full- page, photographic plates from nature. In four 
parts, price, each, $5. Parts I. and II. just ready. Part III. shortly. Limited edition, for 
sale by subscription only. Address the Publishers. 

This, the second part of what bids fair to be the | points of this beautiful work, the second volume 
best teratological treatise extant, is fully up to the \ of which, containing the description of monstrosi- 
previous volume in point of excellence. The i ties, is even more attractive than the first. There 

Elates are superbly executed and the illustrations j are more plates and less space devoted to the 
ave been made with the specimens in the most | text We can only repeat that the work is one 
advantageous positions for purposes of study. — j which reflects great credit upon American ob- 
The Journal of the Anierican Medical Association, stetric literature, and deserves a place in the 
March 5, 1892. library of every specialist and student of anatomy. 

We have already referred at length to the salient | — Medical Be cord, May 21, 1892. 

TBEVES, FBEDEBICK, F. B. C. 8., 

Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital, 
Surgical Applied Anatomy. In one pocket-size 12mo. volume of 540 pages > 
with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manual*, p. 30. 

BELLAMY, EDWABJD, F. B. C. Si, 

Senior Assistant-Surgeon to the Charing-Cross Hospital, London. 

The Student's Guide to Surgical Anatomy : Being a Description of the 
most Important Surgical Regions of the Human Body, and intended as an Introduction to 
Operative Surgery. In one 12mo. volume of 300 pages, with 50 illustrations. Cloth, $2.25. 

WILSON, EBAS31US, F. B. S. 

A System of Human Anatomy, General and Special. Edited by W. H. 
Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of 
Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. 
Cloth, $4.00; leather, $5.00. 

CLELAim, josjsr, m. n., f. b. s., 

Professor of Anatomy and Physiology in Queen's College, Galway. 

A Directory for the Dissection of the Human Body. In one 12mo. 

volume of 178 pages. Cloth, $1.25. 

HARTSHORNE'S HANDBOOK OF ANATOMY I HORNER'S SPECIAL ANATOMY AND HISTOL- 
AND PHYSIOLOGY. Second edition, revised. ! OGY. Eighth edition, extensively revised and 
In one royal 12mo. volume of 310 pages, with 220 modified. In two octavo volumes of 1007 rages, 
woodcuts. Cloth, $1.75. with 320 woodcuts. Cloth, §6.00. 



Lea Brothers & Co.'s Publications — Phy s., Physiol., Anat., Cliem. 7 



BRABER, JOHN €., M. B., LL. B., 

Professor of Chemistry in the University of the City of New York. 
Medical Physics. A Text-book for Students and Practitioners of Medicine. In 
one octavo volume of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. 

No man in America was better fitted than Dr. 
Draper for the task he undertook, and he has pro- 
vided the student and practitioner of medicine 



While all enlightened physicians will agree that 
a knowledge of physics is desirable for the medi- 
cal student, only those actually engaged m the 
teaching of the primary subjects can be fully 
aware of the difficulties encountered by students 
who attempt the study of these subjects without 
a knowledge of either physics or chemistry. 
These are especially felt by the teacher of physi- 
ology. 

It is, however, impossible for him to impart a 
knowledge of the main facts of his subject and 
■establish them by reasons and experimental dem- 
onstration, and at the same time undertake to 
teach ab initio the principles of chemistry or phys- 
ics. Hence the desirability, we may say the 
necessity, for some such work as the present one. 



with a volume at once readable and thorough. 
Even to the student who has some knowledge of 
physics this book is useful, as it shows him its 
applications to the profession that he has chosen. 
Dr. Draper, as an old teacher, knew well the diffi- 
culties to be encountered in bringing his subject 
within the grasp of the average student, and that 
he has succeeded so well proves once more that 
the man to write for and examine students is the 
one who has taught and is teaching them. The 
book is well printed and fully illustrated, and in 
every way deserves grateful recognition.— The 
Montreal Medical Journal, July, 1890. 



BOWER, HENRY, M. B., F. R. C. S., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. Second edition. In one handsome pocket-size 12mo. vol- 
ume of 509 pp., with 68 illustrations. Cloth, $1.50. See Students' Series of Manuals, p. 30. 

BOBEitTsoir, j. McGregor, m. a., m. b., 

Muirhead Demonstrator of Physiology, University of Glasgow. 
Physiological Physics. In one 12mo. volume of 537 pages, with 219 illustra- 
tions. Limp cloth, $2.00. See Students' Series of Manuals, page 30. 



The title of this work sufficiently explains the 
nature of its contents. It is designed as a man- 
ual for the student of medicine, an auxiliary to 
his text-book in physiology, and it would be particu- 
larly useful as a guide to his laboratory experi- 



ments. It will be found of great value to the 
practitioner. It is a carefully prepared book of 
reference, concise and accurate, and as such we 
heartily recommend it.— Journal of the American 
Medical Association, Dec. 6. 1884. 



B ALTON, JOHN C, M. JD., 

Professor Emeritus of Physiology in the College of Physicians and Surgeons, New Fork. 

Doctrines of the Circulation of the Blood. A History of Physiological 
Opinion and Discovery in regard to the Circulation of the Blood. In one handsome 
12mo. volume of 293 pages. Cloth, $2. 



Dr. Dal ton's work is the fruit of the deep research 
of a cultured mind, and to the busy practitioner it 
cannot fail to be a source of instruction. It will 
inspire him with a feeling of gratitude and admir- 
ation for those plodding workers of olden times, 
who laid the foundation of the magnificent temple 
of medical science as it now stands. — New Orleans 
Medical and Surgical Journal, Aug. 1885. 

In the progress of physiological study no fact 
was of greater moment, none more completely 



revolutionized the theories of teachers, than the 
discovery of the circulation of the blood. This 
explains the extraordinary interest it has to all 
medical historians. The volume before us is one 
of three or four which have been written within a 
few years by American physicians. It is in several 
respects the most complete. The volume, though 
small in size, is one of the most creditable con- 
tributions from an American pen to medical history 
that has appeared.— Med. & Surg. Rep., Dec. 6, 1884. 



BELL, F. JEFFREY, 31. A., 

Professor of Comparative Anatomy at King's Collene, London. 

Comparative Anatomy and Physiology. In one 12mo. volume of 561 pages, 
with 229 illustrations. Limp cloth, $2.00. See Students' Series of Manuals, page 30. 

The manual is preeminently a student's book — I it the best work in existence in the English 
<;lear and simple in language and arrangement, language to place in the hands of the medical 
It is well and abundantly illustrated, and is read- i student. — Bristol Medico- Chirurgical Journal, Mar. 
•able and interesting. On the whole we consider [ 1886. 



ELLIS, GEORGE VINER, 

Emeritus Professor of Anatomy in University College, London. 
Demonstrations of Anatomy. Being a Guide to the Knowledge of the 
Human Body by Dissection. From the eighth and revised London edition. In one very 
handsome octavo volume of 716 pages, with 249 illustrations. Cloth, $4.25 ; leather, $5.25. 



ROBERTS, JOHN B., A. M., M. B., 

Lecturer in Anatomy in the University of Pennsylvania. 
The Compend of Anatomy. For use in the dissecting-room and in preparing 
for examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. 

Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Ira Kemsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 



LEHMANN'S MANUAL OF CHEMICAL PHYS- 
IOLOGY. In one octavo volume of 327 pages, 
with 41 illustrations. Cloth, $2.25. 

CARPENTER'S HUMAN PHYSIOLOGY. Edited 
by Henbt Poweb. In one octavo volume. 



CARPENTER'S PRIZE ESSAY ON THE USE AND 
Abuse of Alcoholic Liquors in Health and Dis- 
ease. With explanations of scientific words. Small 
12mo. 178 pages. Cloth, 60 cents. 



8 Lea Brothers & Co.'s Publications — Physiology, Chemistry. 



CHAPMAN, HENRY C., M. I)., 

Professor of Institutes of Medicine and Medical Juris, in the Jefferson Med. Coll. of Philadelphia. 

A Treatise on Human Physiology. In one handsome octavo volume of 
925 pages, with 605 fine engravings. Cloth, $5.50 ; leather, $6.50. 

It represents very fully the existing state of farther, and the latter will find entertainment and 
physiology. The present work has a special value ! instruction in an admirable book of reference.— 



to the student and practitioner as devoted more 
to the practical application of well-known truths 
which the advance of science has given to the 
profession in this department, which may be con- 
sidered the foundation of rational medicine. — Buf- 
falo Medical and Surgical Journal, Dec. 1887. 

Matters which have a practical bearing on the 



practice of medicine are fucidly expressed; tech- V*" "!™» ^"^ 
nical matters are given in minute detail; elabo- ^KfP 1 ? 4 ? *T™ g 9? 
rate directions are stated for the guidance of stu. ' Medieal Aae > * ov - 25 « 



North Carolina, Medical Journal, Not. 1887. 

The work certainly commends itself to both 
student and practitioner. What is most demanded 
by the progressive physician of to-day is an adap- 
tation of physiology to practical therapeutics, and 
this work is a decided improvement in this respect 
over other works in the market. It will certainly 
e most valuable text-books. — 
guidance of stu- ! """"-"* ~u*> »"'• -n 1887 - 
dents in the laboratory. In every respect the j It is the production of an author delighted with 
work fulfils its promise, whether as a complete ! his work, and able to inspire students with an en- 
treatise for the student or for the physician ; for j thusiasm akin to his own.— American Practitioner 
the former it is so complete that he need look no and News, Nov. 12, 1887. 

I) ALTON, JOHN a, m. n., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc 

A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00; leather, $6.00. 

From the first appearance of the book it has I 
been a favorite, owing as well to the author's 
renown as an oral teacher as to the charm of 
simplicity with which, as a writer, he always 
succeeds in investing even intricate subjects. 
It must be gratifying to him to observe the fre- 
quency with which his work, written for students 
and practitioners, is quoted by other writers on 
physiology. This fact attests its value, and, in 
great measure, its originality. It now needs no 
such seal of approbation, however, for the thou- 
sands who have studied it in its various editions 



have never beeD in any doubt as to its sterling 
worth.— N. 7. Medical Journal, Oct. 1882. 

Professor Dalton's well-known and deservedly- 
appreciated work has long passed the stage at 
which it could be reviewed in the ordinary sense. 
The work is eminently one for the medical prac- 
titioner, since it treats most fully of those branches 
of physiology which have a direct bearing on the 
diagnosis and treatment of disease. The work is 
one which we can highly recommend to all our 
readers. — Dublin Journal of Medical Science, Feb.'83. 



FOSTER, MICHAEL, M. D., F. B. 8., 

Prelector in Physiology and Fellow of Trinity College, Cambridge, England. 
Text-Book of Physiology. New (fourth) and enlarged American from the 
fifth and revised English edition, with notes and additions. In one handsome octavo vol- 
ume of 1072 pages, with 282 illustrations. Cloth, $4.50; leather, $5.50. 

the author largely adopted in a modified form in 



The appearance of another edition of Foster's 
Physiology again reminds as of the continued 
popularity of this most excellent work. There 
can be no doubt that this text-book not only con- 
tinues to lead all others in the English language, 
but that this last edition is superior to its prede- 
cessors. Jt is evident that the author has devoted 
a considerable amount of time and labor to its 
preparation, nearly every page bearing evidences 
of carefal revision. Afthough the work of the 
American editor in former editions has been by 



this revision, much was still left to be done by the 
editor to render the work f ally adapted to the wants 
of our American students, so that the American 
edition will undoubtedly continue to supply the 
market on this side of the Atlantic. The work 
has been published in the characteristic creditable 
style of the Lea's, and owing to its enormous sale, 
is offered at an extremely low price. — The Medical 
and Surgical Reporter, Jan. 9, 1892. 



simon, w., Ph. n., m. n., 

Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and 
Professor of Chemistry m the Maryland College of Pharmacy. 

Manual of Chemistry. A Guide to Lectures and Laboratory work for Beginners 
in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
New (third) edition. In one 8vo. volume of 477 pages, with 44 woodcuts and 7 colored 
plates illustrating 56 of the most important chemical tests. Cloth, $3.25. 

Among the many works on chemistry offered I nothing to be desired. As a student's manual this 

I work is of the highest order.— The Medical Neics, 
\ February 20, 1892. 

While possessing all the usual qualities of an 



for the use of the medical student, there is prob- 
ably none that outrivals Dr. Simon's work in prac- 
tical arrangement and thoroughness. A special 
feature of the book, and one that deserves the 

freatest praise, is the presence therein of the 
eautiful colored plates representing fifty-six 
chemical reactions. To say that they are splen- 
didly and artistically executed hardly does them 
justice. They must convey to the mind of the 
student lasting impressions of the color changes 
that he has noted in his experiments in the labor- 
atory, and the perusal of thi-< work must recall 
tnem vividly to recognition. The many cuts are 
well selected, and the make-up of the book leaves 



excellent text-book for the student or laboratory, 
this "Manual" presents the unique advantage of 
furnishing plates showing the variously shaded 
colors of certain chemicals, etc., and their re- 
actions. The chapter on Urinalysis is excellent. 
This "Chemistry" is especially valuable to medi- 
cal students and practitioners, as devoting so 
much of detail to descriptions of analyses, tests, 
etc., of tho?e things witn which the doctor has 
mostly to deal. — Virginia Medical Monthly, Jan- 
uary, 1892. 



CLOWES, FRANK, D. Sc, London, 

Senior Science- Master at the High School, Newcastle-under-Lyme, etc 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one 12mo. volume of 387 pages, with 55 illustrations. Cloth, $2.50. 



Lea Brothers & Co.'s Publications — Chemistry. 



FBANKLANB,E.,I>. C.L.,F.B.S.,&JAPP, F.B. 9 F.I. C, 



Professor of Chemistry in the Normal School 
of Science, London. 



Assist. Prof, of Chemistry in the Normal 
School of Science, London. 



Inorganic Chemistry. In one handsome octavo volume of 677 pages with 51 
woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. 

chemical knowledge is behind the times, would 
do well to study this work. The descriptions and 
demonstrations are made so plain that there is 
no difficulty in understanding them.— Cincinnati 



This work should supersede other works of its 
class in the medical colleges. It is certainly better 
adapted than any work upon chemistry,with which 
we are acquainted, to impart that clear and full 
knowledge of the science which students of med- 
icine should have. Physicians who feel that their 



Medical Neics, January, 1886. 



FOWNES, GEOBGE, Ph. B. 

A Manual of Elementary Chemistry; Theoretical and Practical. Em- 
bodying Watts' Physical and Inorganic Chemistry. New American, from the twelfth English 
edition. In one large royal 12mo. volume of 1061 pages, with 168 illustrations on wood 
and a colored plate. Cloth, $2.75 ; leather, $3.25. 



Fownes* Chemistry has been a standard text- 
book upon chemistry for many years. Its merits 
are very fully known by chemists and physicians 
everywhere in this country and in England. As 
the science has advanced by the making of new 
discoveries, the work has been revised so as to 
keep it abreast of the times. It has steadily 
maintained its position as a textbook with medi- 
cal students. In this work are treated fully : Heat, 
Light and Electricity, including Magnetism. The 
influence exerted by these forces in chemical 
action upon health and disease, etc., is of the most 
important kind, and should be familiar to every 
medical practitioner. We can commend the 



work as one of the very best text-books upon 

chemistry extant. — Cincinnati Med. News, Oct. '85. 

Of all the works on chemistry intended for the 

use of medical students, Fownes' Chemistry is 

Eerhaps the most widely used. Its popularity is 
ased upon its excellence. This last edition con- 
tains all of the material found in the previous, 
and it is also enriched by the addition of Watts' 
Physical and Inorganic Chemistry. All of the mat- 
ter is brought to the present standpoint of chemi- 
cal knowledge. We may safely predict for this 
work a continuance of the fame and favor it enjoys 
among medical students. — New Orleans Medical 
and Surgical Journal, March, 1886. 



ATTFIELB 9 JOHN, M. A., Fh. Z>., F. I. C, F. B. S. 9 Etc. 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; Including the Chem- 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, 
and their Application to Medicine and Pharmacy. A new American, from the twelfth 
English edition, specially revised by the Author for America. In one handsome royal 
12mo. volume of 782 pages, with 88 illustrations. Cloth, $2.75 ; leather, $3.25. 

Attfield's Chemistry is the most popular book 
among students of medicine and pharmacy. This 
popularity has a good, substantial basis. It rests 
upon real merits. Attfield's work combines in the 
happiest manner a clear exposition of the theory 
of chemistry with the practical application of this 
knowledge to the everyday dealings of the phy- 
sician and pharmacist. His discernment is shown 
not only in what he puts into his work, but also in 
what he leaves out. His book is precisely what 
the title claims for it. The admirable arrangement 
of the text enables a reader to get a good idea of 
chemistry without the aid of experiments, and 



again it is a good laboratory guide, and finally it 
contains such a mass of well-arranged information 
that it will always serve as a handy book of refer- 
ence. He does not allow any unutilizable knowl- 
edge to slip into his book; his long years of 
experience have produced a work which is both 
scientific and practical, and which shuts out 
everything in the nature of a superfluity, and 
therein lies the secret of its success. This last 
edition shows the marks of the latest progress 
made in chemistry and chemical teaching. — New 
Orleans Medical and Surgical Journal, Nov. 1889. 



BLOXAM, CBTABLES L., 

Professor of Chemistry in King's College, London. 

Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations. Cloth, $2.00 ; leather, $3.00. 



Comment from us on this standard work is al- 
most superfluous. It differs widely in scope and 
aim from that of Attfield, and in its way is equally 
beyond criticism. It adopts the most direct meth- 
ods in stating the principles, hypotheses and facts 
of the science. Its language is so terse and lucid, 
and its arrangement of matter so logical in se- 
quence that the 



le student never has occasion to 



complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 
the best manuals of general chemistry in the Eng- 
lish language. — Detroit Lancet, Feb. 1884. 



LUFF, ABTMUB P., M.I)., B. &c. 9 

Lecturer on Medical Jurisprudence and Toxicological Chemistry, St. Mary's Hospital Medical 
School, London. 

A Manual of Chemistry. For the use of students of medicine. In one 12mo. 
vol. of 522 pp., with 36 engravings. Cloth, $2.00. See Students' Series of Manuals, p. 30. 

GBEENE 9 WILLIAM H., M. JD. 9 

Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. 

A Manual of Medical Chemistry. For the use of Students. Based upon Bow- 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. 



It is a concise manual of three hundred pages, 
giving an excellent summary of the best methods 
of analyzing the liquids and solids of the body, both 
for the estimation of their normal constituent and 



the recognition of compounds due to pathological 
conditions. The detection of poisons is treated 
with sufficient fulness for the purpose of the stu- 
dent or practitioner. — Boston J I. of Chem. Juute,'80. 



10 Lea Brothers & Co.'s Publications — Chem., Pharm. 

VATJGHAX, VICTOR C, Ph. D., 31. D„ 

Prof, of Pays, and Path. Chem. and Assoc. Prof, of Therap. and Mat. Med. in the Univ. of Mich. 

and JSOVY, FREDERICK G., M. D. 

Instructor in Hygiene and Phys. Chem. in the Univ. of Mich. 

Ptomaines, Leucomaines and Bacterial Proteids ; or the Chemical 
Factors in the Causation of Disease. ]^ew (second) edition. In one handsome 
12mo. volume of 389 pages. Cloth, $2.25, 

The title of this volume brings prominently to by those who had most need of its help, namely, 

view the correct pathology of a host of diseases, general practitioners For the student no more 

Modern chemistry has furnished no more striking important branch of chemistry exists. The early 

evidence of its value than the discovery of these demand for the second edition of a work on so 

ultimate causes of disease, a step which neees- new a department of science, augurs well for the 

sarily precedes any rational knowledge of cure or curriculum in those colleges which have already 

prevention. These successful methods of research made it a branch of study, and for the growing 

nave also thrown a flood of light upon the Leuco- promptness on the part of the profession torecog- 

maines or Physiological Alkaloids. The literature nize and use the most enlightened methods for 

of the subjects, already vast, was before the the benefit of their patients. — The Southern Prao 

preparation of this work scattered and unattainable titioner, December, 1891. 



REMSEW, IRA, M. D., Ph. I)., 

Professor of Chemistry in the Johns Hopkins University, Baltimore. 

Principles of Theoretical Chemistry, with special reference to the Constitu- 
tion of Chemical Compounds. Fourth and thoroughly revised edition. In one handsome 
royal 12mo. volume of 325 pages. Cloth, $2.00. Just ready. 

C MARIES, T. CRANSTOUJV, HI. D., F. C. S., M. S. 9 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 
Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. In one handsome octavo 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. 

Dr. Charles is fully impressed with the impor- ! nowadays. Dr. Charles has devoted much space 
tance and practical reach of his subject, and he to the elucidation of urinary mysteries. He does 
has treated it in a competent and instructive man- this with much detail, and yet in a practical and 
ner. We cannot recommend a better book than intelligible manner. In fact, the author has filled 
the present. In fact, it fills a gap in medical text- his book with many practical hints.— Medical Rec- 
books, and that is a thing which can rarely be said ord, December 20, 1884. 



SOFFMAJSN, F., A.M., Ph.D., & POWER, F.B., Ph.D., 

Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their Identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

It is admirable and the information it under- I explicit. Moreover, it is exceptionally free from 
takes to supply is both extensive and trustworthy. ! typographical errors. We have no hesitation in 
The selection of processes for determining the j recommending it to those who are engaged either 
purity of the substances of which it treats is ex- j in the manufacture or the testing of medicinal 
cellent and the description of them singularly i chemicals. — London Pharm. Jour, and Trans., 1883. 

P ARRIS ET, EDWARD, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia College of Pharviaey. 
A Treatise on Pharmacy : Designed as a Text-book for the Student, and as a 
Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. 
Fifth edition, thoroughly revised, by Thomas S. Wiegand, Ph. G. In one handsome 
octavo volume of 1093 pages, with 256 illustrations. Cloth, $5.00 ; leather, $6.00. 

No thorough-going pharmacist will fail to possess ods of combination are concerned, can afford to 
himself of so useful a guide to practice, and no leave this work out of the list of their works of 
physician who properly estimates the value of an reference. The country practitioner, who must 
accurate knowledge of the remedial agents em- always be in a measure his own pharmacist, will 
ployed by him in daily practice, so far as their find it indispensable.— Louisville Medical News, 
miscibility, compatibility and mos t effective meth- March 29, 1884. 

RALFE, CHARIES M., M. D., F. R. C. P., 

Assistant Physician at the London Hospital. 

Clinical Chemistry. In one pocket-size 12mo. volume of 314 pages, with 16 
illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. 

CLASSED, ALEXANDER, 

Professor in the Royal Polytechnic School, Aix-la-Chapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, 
Edgar F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illus. Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Mat. Med., Therapeutics. 11 



STILLE, A., M.I>.,LL.I>., & MAISCH, J. M., Bhar. D., 

Prof, of Mat. Med. and Botany in Phila. 
College of Pharmacy, Sec' y to the Ameri- 
can Pharmaceutical Association. 



Professor Emeritus of the Theory and Prac- 
tice of Medicine and of Clinical Medicine 
in the University of Pennsylvania. 



The National Dispensatory. 

CONTAINING THE NATURAL HISTORY, CHEMISTRY, PHARMACY, ACTIONS AND USES OF 

MEDICINES, INCLUDING THOSE RECOGNIZED IN THE PHARMACOPEIAS OF THE 

UNITED STATES, GREAT BRITAIN AND GERMANY, WITH NUMEROUS 

REFERENCES TO THE FRENCH CODEX. 

Fourth edition revised, and covering the new British Pharmacopoeia. In one mag- 
nificent imperial octavo volume of 1794 pages, with 311 elaborate engravings. Price 
in cloth, $7.25 ; leather, raised bands, $8.00 ; half Kussia, $9.00. \*This work will be 
furnished with Patent Ready Reference Thumb-letter Index for $1.00 in addition to the price 
in any of the above styles of binding. 
It is with much pleasure that the fourth edition | discovery have received due attention. — Kansas 



of this magnificent work is received. The authors 
and publishers have reason to feel proud of this, 
the most comprehensive, elaborate and accurate 
work of the kind ever printed in this country. It 
is no wonder that it has become the standard au- 
thority for both the medical and pharmaceutical 
profession, and that four editions have been re- 

Suired to supply the constant and increasing 
emand since its first appearance in 1879. The 
entire field has been gone over and the various 
articles revised in accordance with the latest 
developments regarding the attributes and thera- 
peutical action of drugs. The remedies of recent 



City Medical Index, Nov. 1887. 

We think it a matter for congratulation that the 
profession of medicine and that of pharmacy have 
shown such appreciation of this great work as to call 
for four editions within the comparatively brief 
period of eight years. The matters with which it 
deals are of so practical a nature that neither the 

fmysician nor the pharmacist can do without the 
atest text- books on them, especially those that are 
so accurate and comprehensive as this one. The 
book is in every way creditable both to the authors 
and to the publishers. — New York Medical Journal, 
May 21, 1887. 



MAISCH, JOHNM., JPhar. L>., 

Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 

A Manual of Organic Materia Medica; Being a Guide to Materia Medica of 
the Vegetable and Animal Kingdoms. For the use of Students, Druggists, Pharmacists 
and Physicians. New (fifth) edition, thoroughly revised. In one very handsome 12mo. 
volume of 544 pages, with 270 engravings. Cloth, $3.00. Just ready. 

A notice of the previous edition is appended. 



For everyone interested in materia medica, 
Maisch's Manual, first published in 1882, and now 
in its fourth edition, is an indispensable book. 
For the American pharmaceutical student it is 
the work which will give him the necessary knowl- 
edge in the easiest way, partly because the text is 
brief, concise, and free from unnecessary matter, 
and partly because of the numerous illustrations, 
which bring facts worth knowing immediately be- 



fore his eyes. That it answers its purposes in this 
respect the rapid succession of editions is the best 
evidence. It is the favorite book of the American 
student even outside of Maisch's several hundred 
personal students. The arrangement of its con- 
tents shows the practical tendency of the book. 
Maisch's system of classification is easy and com- 
prehensive.— Pharmaceutische Zeitung, Germany, 
1890. 



EBES, BOBEBT T. 9 M. Z>., 

Jackson Professor of Clinical Medicine in Harvard University, Medical Department. 

A Text-Book of Therapeutics and Materia Medica. Intended for the 
Use of Students and Practitioners. Octavo, 544 pages. Cloth, $3.50 ; leather, $4.50. 



It possesses all the essentials which we expect 
in a book of its kind, such as conciseness, clear- 
ness, a judicious classification, and a reason- 
able degree of dogmatism. All the newest drugs 
of promise are treated of. The clinical index at 
the end will be found very useful. We heartily 
commend the book and congratulate the author 



on having produced so good a one.— N. Y. Medical 
Journal, Feb. 18, 1888. 

Dr. Edes' book represents better than any older 
book the practical therapeutics of the present 
day. The book is a thoroughly practical one. The 
classification of remedies has reference to their 
therapeutic action. — Pharmaceutical Era, Jan. 1888. 



BBUCE, J. MITCHELL, M. I>., F. B. C. P., 

Physician and Lecturer on Materia Medica and Therapeutics at Charing Cross Hospital, London. 

Materia Medica and Therapeutics. An Introduction to Rational Treatment. 
Fifth edition. 12mo., 591 pages. Cloth, $1.50. See Students' Series of Manuals, page 30. 

GBIFFITBE, BOBEBT EGLESFIELD, M. 2>. 

A Universal Formulary, containing the Methods of Preparing and Adminis- 
tering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceut- 
ists. Third edition, thoroughly revised, with numerous additions,, by John M. Maisch, 
Phar.D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. 
In one octavo volume of 775 pages, with 38 illustrations. Cloth, $4.50 ; leather, $5.50. 



HERMANN'S EXPERIMENTAL PHARMACOL- 
OGY. A Handbook of Methods for Determining 
the Physiological Action of Drugs. Translated, 
with the Author's permission, and with exten- 
sive additions, by R. M. Smith, M. D. 12mo., 
199 pages, with 32 illustrations. Cloth, $1.50. 



STILLE'S therapeutics and materia 
MEDICA. A Systematic Treatise on the Action 
and Uses of Medicinal Agents, including their 
Description and History. Fourth edition, re- 
vised and enlarged. In two octavo volumes, con- 
taining 1936 pages. Cloth, $10.00 ; leather, $12.00. 



12 Lea Brothers & Co.'s Publications— Mat. Med., Therapeutics. 



A SYSTEM OF PRACTICAL THERAPEUTICS 

BY AMERICAN AND FOREIGN AUTHORS. 

Edited by HOBART AMORY HARE, M. D., 

Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. 

Assisted by Walter Chrystie, M. D., Formerly Instructor in Physical 
Diagnosis in the University of Penna. 
In a series of contributions by seventy-eight eminent authorities. In three large 
octavo volumes of about 1100 pages each, with illustrations. Vols. I., II. and III. just 
ready. ^ Price, per volume: Cloth, $5.00; leather, $6.00; half Russia, $7.00. For sale by 
subscription only. Address the Publishers. Full prospectus free to any address on application. 
I^.our notices of the two preceding volumes | commend it as a most valuable contribution to 
magnificent work we spoke highly of its j the medical literature of the day.— Nashville Jour- 



of th 

merits as an encyclopedic reference "book, and 
commended it to the profession as the most per- 
fect work of the kind. The third volume has 
already appeared, following the other two in an 
almost incredibly short time, and in every respect 
the equal of its predecessors. We fell that we 
cannot say too much for this System. It is exactly 
what the practitioner needs for daily reference. 
All diseases are treated of in their etiology, 
pathology and symptomatology, and the applica- 
tion of medicines to their management fully 
given. Every subject is handled by a writer who 
has devoted himself especially to its considera- 
tion, so that the system is really a collection of 
monographs by writers who are authorities upon 
the subjects. In the list of authors, of which 
their are forty for this volume, we observe the 
names of some of the best-known American 
physicians, who have distinguished themselves by 
their works or their writings in the special depart- 
ments in which they have labored. No one who 
desires to keep in the van of professional advance 
can afford to be without it. We unhesitatingly 



nal of Medicine and Surgery, Julyj 1892. 

In the volumes of Dr. Hare's System will be 
found a series of articles, for the most part 
admirably concise and clearly written, which deal 
with the treatment of the patient in plain common- 
sense style, and are sufficiently subdivided into 
sections to permit of easy reference. Each 
article being contributed by a writer whose public 
position or private practice enables him to speak 
with a full knowledge of the possibilities as well 
as the impossibilities of treatment in the particular 
branch of therapeutics with which he deals, the 
information which is contained therein may be 
accepted as essentially trustworthy, and will be 
found eminently practical. Space will not admit 
of reference to the many useful and practical 
articles in these handsome volumes. As a store- 
house of information on the treatment of disease, 
whether practical or theoretical, the whole work 
deserves a prominent place among the established 
" Systems " which constitute our most trustworthy 
guides in any medical difficulty.— Brisish Medical 
Journal, June 25, 1892. 



HARE, HOBART AMORY, B. Sc, M. JD., 

Professor of Materia Medica and Therapeutics in the Jefferson Medical College of Philadelphia; 
Secretary of the Convention for the Revision of the United States Pharmacopoeia of 1890. 

A Text-Book of Practical Therapeutics ; With Especial Reference to the 
Application of Remedial Measures to Disease and their Employment upon a Rational 
Basis. With special chapters by Drs. Gr. E. de Schweinitz, Edward Martin, 
J. Howard Reeves and Barton C. Hirst. New (2d) and revised edition. In one 
handsome octavo volume of 650 pages. Cloth, $3.75 ; leather, $4.75. 

This work has received the rare distinction 
among medical works of reaching a second edition 



six months after its first appearance. Many new 
prescriptions have also been inserted to illustrate 
the best modes of applying remedies. Among 
other features of this practically helpful treatise 
which will make reference to it convenient and 
profitable, are the arrangement of titles of drugs 



and diseases in alphabetical order, according to 
their English names; and a dose list of drugs 
officinal and unofficinal. In addition to the gen- 
eral index, a copious and explanatory index of 
diseases and remedies has been appended which 
will render the contents easily accessible. — The 
Medical Age, July 10, 1891. 



BRTJNTOJS, T. LAUDER, 31. JD., JD.Sc, F.R.S., F.R.C.JP., 

Lecturer on Materia Medica and Therapeutics at St. Bartholmneio' s Hospital, London, etc. 

A Text-Book of Pharmacology, Therapeutics and Materia Medica; 

Including the Pharmacy, the Physiological Action and the Therapeutical Uses of Drugs. 
Adapted to the U. S. Pharmacopoeia by Francis H. Williams, M. D., of Harvard Univer- 
sity Medical School. Third edition. Octavo, 1305 pages, 230 illustrations. Cloth, $5.50 ; 
leather, $6.50. 

No words of praise are needed for this work, for J made 'in various directions in the art of therapeu- 
it has already spoken for itself in former editions. I tics, and it now stands unrivalled in its thoroughly 
It was by unanimous consent placed among the I scientific presentation of the modes of drug action, 
foremost books on the subject ever published in No one who wishes to be fully up to the times in 
any language, and the better it is known and studied j this science can afford to neglect the study of Dr. 
the more highly it is appreciated. The present i Brunton's work. The indexes are excellent, and 
edition contains much new matter, the insertion | add not a little to the practical value of the book, 
of which has been necessitated by the advances , —Medical Record, May 25, 1SS9. 

FARQUHARSOW, ROBERT, M. JD., F. R. C. P., LL. JD., 

Lecturer on Materia Medica at St. Mary's Hospital, Medical School, London. 

A Guide to Therapeutics and Materia Medica. Fourth American, 
from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia. By 
Frank Woodbury, M. D., Professor of Materia Medica and Therapeutics and Clinical 
Medicine in the Medico-Chirurgical College of Philadelphia. In one handsome 12mo. 
volume of 581 pages. Cloth, $2.50. 

It may correctly be regarded as the most modern | copoeias, as well as considering all non-official but 
work of its kind. It is concise, yet complete, important new drugs, it becomes in fact a miniature 
Containing an account of all remedies that have dispensatory.— Pacific Medical Journal, June, 1889. 
a place in the British and United States Pharma- | 



Lea Brothers & Co.'s Publications — Practice of Med. 



13 



FLINT, AUSTIN, M. D., LL. I)., 

Prof, of the Principles and Practice of Med. and of Clxn. Med. in Bellevue Hospital Medical College, N. Y. 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. Sixth edition, thoroughly revised 
and rewritten by the Author, assisted by William H. Welch, M. D., Professor of 
Pathology, Johns Hopkins University, Baltimore, and Austin Flint, Jr., M. D., LL. D., 
Professor of Physiology, Bellevue Hospital Medical College, N. Y. In one very handsome 
octavo volume of 1160 pages, with illustrations. Cloth, $5.50 ; leather, $6.50. 

in city, town, village, or at some cross-roads, is 
Flint's Practice. We make this statement to a 
considerable extent from personal observation, and 



No text-book on the principles and practice of 
medicine has ever met in this country with such 
general approval by medical students and practi- 
tioners as the work of Professor Flint. In all the 
medical colleges of the United States it is the fa- 
vorite work upon Practice; and, as we have stated 
before in alluding to it, there is no other medical 
work that can be so generally found in the libra- 
ries of physicians. In every state and territory 
of this vastcountry the book that will be most likely 
to be found in the office of a medical man, whether 



it is the testimony also of others. An examina- 
tion shows that very considerable changes have 
been made in the sixth edition. The work may un- 
doubtedly be regarded as fairly representing the 
present state of the science of medicine, and as 
reflecting the views of those who exemplify in 
their practice the present stage of progress of med- 
ical art. — Cincinnati Medical Newt, Oct. 1886. 



BBISTOWE, JOHN STUB, M. JD., LL. JD., F. B. S., 

Senior Physician to and Lecturer on Medicine at St. Thomas' Hospital, London. 

A Treatise on the Science and Practice of Medicine. Seventh edi- 
tion. In one large octavo volume of 1325 pages. Cloth, $6.50 ; leather, $7.50. 

tion, systematic, scientific and practical, contain- 
ing the matured experience of a physician who 
has every claim to be considered an authority, 



Dr. Bristowe's now famous treatise appears in 
its seventh edition. It has long passed the stage 
in which it requires critical examination or com- 
mendation, and has thoroughly established itself 
as among the most complete and useful of text- 
books.— British Medical Journal, September 27, 1890. 

It is a work that is built on a stable founda- 



and composed in a style which attracts the prac- 
titioner as much as the student. No one can say 
that this book has obtained a success which was 
undeserved.— The Lancet, July 12, 1890. 



HABTSHOBNE, HENBY, M. JD., LL. !>., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 
for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 
royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75. 

a better average of actual practical treatment than 



Within the compass of 600 pages it treats of the 
history of medicine, general pathology, general 
symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen. — Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 



this one; and probably not one writer in our day 
had a better opportunity than Dr. Hartshorne for 
condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials are most valuable in affording the means to 
see at a glance the whole literature of any disease, 
and the most valuable treatment. — Chicago Medical 
Journal and Examiner, April, 1882. 



BEYNOLDS, J. BUSSELL, M. JD., 

Professor of the Principles and Practice of Medicine in University College, London. 
A System of Medicine. With notes and additions by Henry Hartshorne, 
A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. In three large 
and handsome octavo volumes, containing 3056 double-columned pages, with 317 illustra- 
tions. Price per volume, cloth, $5.00; sheep, $6.00; half Russia, raised bands, $6.50. 
Per set, clotb, $15.00; leather, $18.00; half Russia, $19.50. Sold only by subscription. 



COHEN, SOLOMON SOLIS, M. JD., 

Professor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic. 

A Handbook of Applied Therapeutics. Being a Study of Principles 
Applicable and an Exposition of Methods Employed in the Management of the Sick. 
In one large 12mo. volume, with illustrations. Preparing. 



STILLE ON CHOLERA: Its Origin, History, 
Causation, Symptoms, Lesions, Prevention and 
Treatment. In one handsome 12mo. volume of 
163 pages, with a chart. Cloth, 81.25. 

WATSON'S LECTURES ON THE PRINCIPLES 
AND PRACTICE OF PHYSIC. From the fifth 
English edition. Edited with additions, and 190 
illustrations, by Henry Hartshorne, A.M., M. D., 
late Professor of Hygiene in the University of 
Pennsylvania. In two large octavo volumes of 
1840 pages. Cloth, $9.00; leather, 811.00. 

FLINT ON PHTHISIS: ITS MORBID ANAT- 
OMY, ETIOLOGY, SYMPTOMATIC EVENTS 



AND COMPLICATIONS, FATALITY AND 
PROGNOSIS, TREATMENT AND PHYSICAL 
DIAGNOSIS; in a series of Clinical Studies. In 
one octavo volume of 442 pae;es. Cloth, 83.50. 

FLINT'S PRACTICAL TREATISE ON THE 
DIAGNOSIS, PATHOLOGY AND TREATMENT 
OF DISEASES OF THE HEART. Second re- 
vised and enlarged edition. In one octavo vol- 
ume of 550 pages, with a plate. Cloth, $4. 

FLINT'S ESSAYS ON CONSERVATIVE MEDI- 
CINE AND KINDRED TOPICS. In one very 
handsome royal 12mo. volume of 210 pages. 
Cloth, 81.38. 



14 Lea Brothers & Co.'s Publications — System of Med. 

Tor Sale by Subscription Only. 



A System of Practical Medicine. 

BY AMERICAS AUTHORS. 
Edited by WILLIAM PEPPER, M. D.. LL. D., 

PROYOST AST) PROFESSOR OF THE THEORY A2TD PRACTICE OF MEDICDTE A2TD OF 
CLTS1CAL MEDICTSE EH THE UyiVERSITY OF PE^rS-STXYASTA. 

Assisted by Louis Starr, M. D., Clinical Professor of the Diseases of Children in the 
Hospital of the University of Pennsylvania. 

The complete work, in tire volumes, containing 5573 pages, vith 198 Ulustratwns t is now ready. 
Price per volume, cloth, $5; leather, $6 ; half Russia, raised bands and open bad:. | " 



In this great work American medicine is for the first time reflected by its worthiest 
teachers,, and presented in the fall development of the practical utility which is its pre- 
eminent characteristic. The most able men — from the East and the West, from the 
North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities for study and practice — have united in 
generous rivalry to bring together this vast aggregate of specialized experience. 

The distinguished editor has so apportioned the work that to each author has been 
assigned the subject which he is peculiarly fitted to discuss, and in which his views 
will be accepted as the latest expression of scientific and practical knowledge. The 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with full certainty of finding what he needs 
in its most recent aspect, whether he seeks information on the general principles of medi- 
cine, or minute guidance in the treatment of special disease. So wide is the scope of the 
work that, with the exception of midwifery and matters strictly surgical, it embraces the 
whole domain of medicine, including the departments for which the physician is accustomed 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs., of the skin, of the nerves, hygiene and sanitary science, and medical ophthalmology 
and otology. Moreover, authors have inserted the formulas which they have found most 
efficient in the treatment of the various affections. It may thus be truly regarded as a 
Complete Library of Practical Mfj)Icts~e, and the general practitioner possessing it 
may feel secure that he will require little else in the daily round of professional d nl 

In spite of every effort to condense the vast amount of practical information fur- 
nished, it has been impossible to present it in less than 5 large octavo volumes, containing 
about 5600 beautifully printed pages, and embodying the matter of about 15 ordinary 
octavos. Illustrations are introduced wherever requisite to elucidate the text. 

A detailed prospectus \cill be sent to any address on application to the publishers. 

TbBUB ~.~ : ■ Btan m a I ring this admirable work physic: si - ; 

to s close, and fu.-j rmfrtnin Hm high standard ties of climate in the united St ates, - :.-.aracter 

reached by the earlier volumes ; we ha^e only of the ?::.. the manners an i irMrtwinw of the peo- 

therefore to echo the eulogium pronounced upon pie, etc, it is peculiarly adapted to the wants 

them. We would warmly congratulate the editor of American practitioners of medicine, and it 

■ad hie : laborators at'the conclusion of their seems:-: Bfi taafl every one of them would desire 

laborious task on the admirable manner in which, to have it. It has been truly called a "Complete 

from frs: :-: ".as:. -.hey have performed their several Library of Practical Medicine," and the general 

duties. Thev have succeeded in producing a practitioner will require liule else in his round 

work which will iong remain a standard work of of professional duties,— Cincinnati Medical Sews, 

r eferen ce, to which practitioners will look for March, 1886. 

guidance, and authors will resort for facts. Each of the volumes is provided with a most 

rom a literary point of vie-, the not* : ; without copious index, and the work altogether promises 

sh, and in respect of production, to be one which will add much to the medical 

it has the beautiful finish that Americans always literature of the present century, and reflect great 

tear w :.->».— Edinburgh Medical Journal, Jan. credit upon the scholarship and practical acumen 
■M hot -— : ie London Lancet, Oct. 3, 1885. 

•* The greatest distinctively American work on The feeling of proud satisfaction with wh i 
the practice of medicine, and, indeed, the super- American profession sees this, its re] 
larive adjective would not be inappropriate were system of practical medicine issued to the medi- 
even all other productions placed in comparison, cal world, is fully justified by the character of the 
An examination of the five volumes is sufficient work. . be tain easte ■ is in keep- 
to convince one of the magnitude of the enter- ing with the best thoughts of the leaders and fol- 
prise, and of I - meeaas which has attended its lowers of our home school of medicine, and the 
fulfilment.— The Medical Aae, July 26, 1886. combination of the scientific study of disease and 

This huge volume forms a fitting close to the the practical application of exact and experimen- 

great system of medicine which in so short a time tal knowledge to the :rea:n:ent of human mal- 

has won so high a place in medical literature, and ai rt are in the pride 

has done such credit to the profession in this that has welcomed Dr. Peppers labors. Sheared 

country. Among the twenty-three contributors of the prolixity thai wearies the readers of the 

are the names of the leading neurolosists in German school, the articles clean these same 

America, and most of the work in the volume is of fields for all that is valuable, ft is the outcome 

the highest order.— Boston Medical and Surgical of American brains, and is marked throughout 

Journal, July 21,1887. by much of the sturdy independence of thought 

Vie consider it one of the grander vnrioi on and originality that is a national characteiiatie. 

Practical Medicine in the English language. It is Yet nowhere is there lack of study of the most 

a work of which the profession of this country can advanced views of the day.— Xorth Carolina Mtd\- 

feel proud. V*r American cal Journal, Sept. 188*. 



Lea Brothers & Co.'s Publications — Practice of Medicine. 15 



LYMAN, MENUY M. 9 31. JD., 

Professor of the Principles and Practice of Medicine, Rush Medical College, Chicago. 

The Principles and Practice of Medicine. For the Use of Medical Students 
and Practitioners. In one very handsome octavo volume of 925 pages, with 170 illustra- 
tions. Cloth, $4.75. Just ready. 

The author has undertaken to present in this volume not only the results of his long 
experience as a practitioner and teacher, but to make it representative of the latest state 
of knowledge in its department. The work is assured of wide use as an unsurpassed guide 
for the student and likewise for the practitioner. 

WHITLA, WILLIAM, M. JD., 

Projessor of Materia Medica and Therapeutics in the Queen's College, Belfast. 

A Dictionary of Treatment ; or Therapeutic Index, including Medi- 
cal and Surgical Therapeutics. Eevised and adapted to the United States 
Pharmacopoeia. In one square, octavo volume of 917 pages. Cloth, $4.00. Just ready. 



Dr. Whitla has, we think, been fortunate in the 
selection of a title for his latest work. We have 
already dictionaries of medicine and dictionaries 
of surgery; he now provides us with a dictionary 
of treament. And reference to the volume shows 
that it really is what it professes to be. The sev- 
eral diseased conditions are arranged in alphabet- 
ical order, and the methods— medical, surgical, 
dietetic, and climatic — by which they may be met, 
considered. On every page we find clear and de- 
tailed directions for treatment, supported by the 
author's personal authority and experience, whilst 
the recommendations of other competentobservers 
are also critically examined. The book abounds 
with useful, practical hints and suggestions, and 



the younger practitioner will find in it exactly the 
help he so often needs in the treatment both of 
those who are ill, and those who are ailing. At the 
same time the most experienced members of the 
profession may usefully consult its pages for the 
purpose of learning what is really trustworthy in 
the Jater therapeutic developments. The Diction- 
ary is, in short, the recorded experience of a prac- 
tical scientific therapeutist, who has carefully 
studied diseases and disorders at the bed-side and 
in the consulting-room, and has earnestly ad- 
dressed himself to the cure and relief of his 
patients. Dr. Whitla is to be congratulated upon 
the thoroughness with which he has realised his 
idea.— The Glasgow Medical Journal, April, 1892. 



FOTHEBGILL, J. M., 31. JD., Edin., M. JR. C. JP., Lond., 

Physician to the City of London Hospital fo^ Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. Third edition. In one 8vo. vol. of 661 jsages. Cloth, $3.75 ; leather, $4.75. 

To have a description of the normal physiologi- 
cal processes of an organ and of the methods of 
treatment of its morbid conditions brought 
together in a single chapter, and the relations 
between the two clearly stated, cannot fail to prove 
a great convenience to many thoughtful but busy 
physicians. The practical value of the volume is 
greatly increased by the introduction of many 

? inscriptions. That the profession appreciates 
hat the author has undertaken an important work 
and has accomplished it is shown by the demand 
for this third edition. — N. ¥. Med. Jour., June 11, '87. 



This is a wonderful book. If there be such a 
thing as " medicine made easy," this is the work to 
accomplish this result. — Va. Med. Month., June,'87. 

It is an excellent, practical work on therapeutics, 
well arranged and clearly expressed, useful to the 
student and young practitioner, perhaps even to 
the old. — Dublin Journal of Medical Science, March, 
1888. 

We do not know a more readable, practical and 
useful work on the treatment of disease than the 
one we have now before us.— Pacific Medical and 
Surgical Journal, October, 1887. 



FINLAYSON, JAMES, M. JO., Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 

Clinical Manual for the Study of Medical Cases. With Chapters 
by Prof. Gairdner, Prof. Stephenson, Dr. Robertson, Dr. Gemmell and Dr. Coats. Second 
edition. In one 12mo. volume of 682 pages, with 158 illustrations. Cloth, $2.50. 



We are pleased to see a second edition of this 
admirable book. It is essentially a practical 
treatise on medical diagnosis, in which every sign 
and symptom of disease is carefully analyzed, and 
their relative significance in the different affec- 
tions in which they occur pointed out. From their 
synthesis the student can accurately determine 
the disease with which he has to deal. The book 



has no competitor, nor is it likely to have as long 
as future editions maintain its present standard of 
excellence. The general practitioner will find 
many practical hints in its pages, while a careful 
study of the work will save him from many pitfalls 
in diagnosis. — Liverpool Medico- Chirurgical Jour- 
nal, January, 1887. 



MUSSEJR, JOHN H„ M. !>., 

Assistant Professor of Clinical Medicine, University of Pennsylvania, Philadelphia. 

A Practical Treatise on Medical Diagnosis. For the Use of Students and 
Practitioners. In one octavo volume of about 650 pages. Preparing. 

HABEBSHON, S. O., M. !>., 

Senior Physician to and late Lect. on Principles and Practice of Med. at Guy's Hospital, London. 

On the Diseases of the Abdomen ; Comprising those of the Stomach, and 
other parts of the Alimentary Canal, (Esophagus, Csecum, Intestines and Peritoneum. Second 
American from third enlarged and revised English edition. In one handsome octavo 
volume of 554 pages, with illustrations. Cloth, $3.50. 

This valuable treatise on diseases of the stomach 
and abdomen will be found a cyclopaedia of infor- 
mation, systematically arranged, on all diseases of 
the alimentary tract, from the mouth to the 



rectum. A fair proportion of each chapter is 
devoted to symptoms, pathology, and therapeutics. 
— New York Medical Journal, April, 1879. 



TANNER'S MANUAL OF CLINICAL MEDICINE 
AND PHYSICAL DIAGNOSIS. Third American 
from the second London edition. Revised and 
enlarged by Tilbury Fox, M.D. In one 12mo. 
volume of 362 pp., with illus. Cloth, S1.50. 

A TREATISE ON FEVER. By Robert D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25. 



LECTURES ON THE STUDY OF FEVER. By 
A. Hudson , M. D., M. R. I. A. In one octavo 
volume of 308 pages. Cloth, $2.50. 

LA ROCHE ON YELLOW FEVER, considered in 
its Historical, Pathological, Etiological and 
Therapeutical Relations. In two large and hand- 
some octavo volumes of 1468 pp. Cloth, 87.00. 



16 Lea Brothers & Co.'s Publications — Hygiene, Electr., Pract. 



BARTHOLOW, ROBERTS, A. M., M. JD. 9 LL. !>., 

Prof, of Materia Medica and General Therapeutics in the Jefferson Med. Coll. of Phila., etc 
Medical Electricity. A Practical Treatise on the Applications of Electricity 



to Medicine and Surgery. Third edition, 
pages, with 110 illustrations. Cloth, $2.50. 

The feet that this work has reached its third edi- 
tion in six years, and that it has been kept fully 
abreast with the increasing use and knowledge of 
electricity.demonstrates its claim to be considered 
a practical treatise of tried value to the profession. 
Tne matter added to the present edition embraces 



In one very handsome octavo volume of 308 



the most recent advances in electrical treatment. 
The illustrations are abundant and clear, and the 
work constitutes a full, clear and concise manual 
well adapted to the needs of both student and 
practitioner.— The Medical News, May 14, 1887. 



YEO, I. BURNEY, M. D., F. R. C. P., 

Professor of Clinical Therapeutics in King's College, London, and Physician to King's College 
Hospital. 

Pood in Health and Disease. In one 12mo. volume of 590 pages. Cloth, $2. 
See Series of Clinical Manuals, page 31. 

Dr. Yeo supplies in a compact form nearly all that ! compass, and he has arranged and digested his 
the practitioner requires to know on the subject of } materials with skill for the use of the practitioner. 
diet. The work is divided into two parts— food in ; We have seldom seen a book which more thor- 
health and food in disease. Dr. Yeo has gathered ; oughly realizes the object for which it was written 
together from all quarters an immense amount of '■ than this little work of Dr-. Yeo.— British Medical 
useful information within a comparatively small | Journal, Feb. 8, 1890. 

RICHARDSON, B. TV., M.D., LL. I)., F.R.S., 

Fellow of the Royal College of Physicians, London. 
Preventive Medicine. In one octavo volume of 729 pages. Cloth, $4; leather. $5. 

tive collection of data upon the diseases common 



Dr. Richardson has succeeded in producing a 
work which is elevated in conception, comprehen- 
sive in scope, scientific in character, systematic in 
arrangement, and which is written in a clear, con- 
cise and pleasant manner. He evinces the happy 
faculty of extracting the pith of what is known on 
the subject, and of presenting it in a most simple, 
intelligent and practical form. There is perhaps 
no similar work written for the general public 
thatcontains such a complete, reliable and instruc- 



to the race, their origins, causes, and the measures 
for their prevention. The descriptions of diseases 
are clear, chaste and scholarly ; the discussion of 
the question of disease is comprehensive, masterly 
and fully abreast with the latest and best knowl- 
edge on the subject, and the preventive measures 
advised are accurate, explicit and reliable. — The 
American Journal of the Medical Sciences, April, 1884. 



THE YEAR BOOK OF TREATMENT FOR 1892. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine and Surgery. In one 12mo. vol. of about 500 pages. Cloth, $1.50. Just ready. 
#** For special commutations with periodicals see pages 1 and 2. 
The "Year-Book" is too well known and too j concise and readable form. Thus, with compara- 
highly appreciated to need comment. The lm- | tively little labor, the busy practitioner gets the 
mense strides taken in the progress of medicine j gist of medical literature the world over. Every 
in all its branches make it impossible for anyone branch of medicine is overed— new remedies, old 
to keep up with the times. Hence the necessity I ones with new applications, new operations, all 
of the book in hand. Its score of co-authors sift j receiving attention. — Meaical Record, May 21, 1892. 
out what is useful in literature and present it in a | 

THE YEAR-BOOK OF TREATMENT FOR 1891. 

12mo., 485 pages. Cloth, $1.50. 

THE YEAR- BOOKS of TREATMENT for '86, '87 and '90 

Similar to above. 12mo., 320-341 pages. Limp cloth, $1.25 each. 

SCHREIBER, JOSEPH, 31. L>. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of 274 pages, with 117 fine engravings. 



STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, $1.25. 

DAVIS' CLINICAL LECTURES ON VARIOUS 
IMPORTANT DISEASES. By N. S. Davis, 
M. D. Edited by Fbaxk H. Davis, M. D. Second 
edition. 12mo. 287 pages. Cloth, 81.75. 

TODD'S CLINICAL LECTURES ON CERTAIN 
ACUTE DISEASES. In one octavo volume of 
320 pages. Cloth. 82.50. 

PAVY'S TREATISE ON THE FUNCTION OF DI- 
GESTION; its Disorders and their Treatment. 
From the second London edition. In one octavo 
volume of 238 pages. Cloth, $2.00. 

BARLOW'S MANUAL OF THE PRACTICE OF 
MEDICINE. With additions by D. F. Condie, 
M. D. 1 vol. 8vo., pp. 603. Cloth, $2.50. 

CHAMBERS' MANUAL OF DIET AND REGIMEN 
IN HEALTH AND SICKNESS. In one hand 
some octavo volume of 302 pp. Cloth, $2.75. 



HOLLAND'S MEDICAL NOTES AND REFLEC- 
TIONS. 1 vol. 8vo., pp. 493. Cloth, 83.50. 

FULLER ON DISEASES OF THE LONGS AND 
AIR-PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, 83-50. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, 83.00. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Countries. Second and revised 
j edition. In one 12mo. vol., 158 pp. Cloth. 81.25. 

SMITH ON CONSUMPTION; its Early and Reme- 
diable Stages. 1 vc!. 8vo., 253 pp. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, 83.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 303 pp. Clotn, $2.50. 



Lea Brothers & Co.'s Publications — Phys. Diagr., Throat, Hist. 17 



FLINT, AUSTIN, M. D., LL. D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. 7. 

A. Manual of Auscultation and Percussion; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth edition. 
Edited by James C. Wilson, M. D., Lecturer on Physical Diagnosis in the Jefferson 
Medical College, Philadelphia. In one handsome royal 12mo. volume of 274 pages, with 
12 illustrations. Cloth, $1.75. 



This little book through its various editions has 
probably done more to advance the science of 

Shysical exploration of the chest than any other 
issertation upon the subject, and now in its fifth 
edition it is as near perfect as it can be. The 
rapidity with which previous editions were sold 
shows how the profession appreciated the thor- 



oughness of Prof. Flint's investigations. For stu- 
dents it is excellent. Its value is shown both in 
the arrangement of the material and in the clear, 
concise style of expression. For the practitioner 
it is a ready manual for reference.— North Ameri- 
can Practitioner, January, 1891. 



BBOADBENT, W. M., M. D., F. B. C. P., 

Physician to and Lecturer on Medicine at St. Mary's Hospital, London. 
The Pulse. In one 12mo. volume of 312 pages. Cloth, $1.75. 
ical Manuals, page 31 



See Series of Clin- 



BROWNE, LENNOX, F. B. C. S., E., 

Senior Physician to the Central London Throat and Ear Hospital. 

The Throat and Nose and Their Diseases. Fourth and enlarged edition. 
In one imperial octavo volume of about 750 pages, with 120 illustrations in color, and 235 
engravings on wood. Preparing. 

A notice of the previous edition is appended. 

The beautiful and typical colored plates form 
a valuable and instructive atlas, the equal of which 
is not to be found in any modern work, treating 
of these subjects. Mr. Lennox Browne is to be 
congratulated on having produced the best prac- 



tical text-book on diseases of the throat and nose 
extant. We are glad to learn that it is being 
translated into French and German. — The Provin- 
cial Medical Journal, August 1, 1890. 



SEILEB, CABL, M. !>., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. New (4th) edition. In one handsome royal 12mo. volume 
of about 400 pages, with 101 illustrations and 2 colored plates. Preparing. 

A notice of the previous edition is appended. 
Few medical writers surpass this author in of topics and methods. The book deserves a large 
ability to make his meaning perfectly clear in a sale, especially among general practitioners— Chi- 
few words, and in discrimination in selection, both cago Medical Journal and Examiner, April, 1889. 



COHEN, J. SOLIS, M. I)., 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest in the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 



SCHAFEB, EDWARD A., F. B. S., 

Jodrell Professor of Physiology in University College, London. 

The Essentials of Histology. New (second) edition. 
of 311 pages, with 325 illustrations. Cloth, $3.00. Just ready. 



In one octavo volume 



KLEIN, E., M. D., F. B. S., 

Joint Lecturer on General Anat. and Phys. in the Med. School of St. Bartholomew's Hosp., London. 

Elements of Histology. Fourth edition. In one 12mo. volume of 376 pages, 
with 194 illus. Limp cloth, $1.75. See Students 7 Series of Manuals, page 30. 



FLINT'S PRACTICAL TREATISE ON THE 
PHYSICAL EXPLORATION OF THE CHEST 
AND THE DIAGNOSIS OF DISEASES AF- 
FECTING THE RESPIRATORY ORGANS. 
Second and revised edition. In one handsome 
octavo volume of 591 pages. Cloth, $4.50. 

BROWNE ON KOCH'S REMEDY IN RELATION 
TO THROAT CONSUMPTION. In one octavo 
volume of 121 pages, with 45 illustrations, 4 of 
which are colored, and 17 charts, Cloth, $1.50. 

GROSS' PRACTICAL TREATISE ON FOREIGN 



BODIES IN THE AIR-PASSAGES. In one 
octavo volume of 452 pages, with 59 illustrations. 
Cloth, $2.75. 

WOODHEAD'S PRACTICAL PATHOLOGY. A 
Manual for Students and Practitioners. In one 
beautiful octavo volume of 497 pages, with 136 
exquisitely colored illustrations. 

PEPPER'S SURGICAL PATHOLOGY. In one 
pocket-size 12mo. volume of 511 pages, with 81 
illustrations. Limp cloth, red edges, $2.00. See 
Students' Series of Manuals, page 31. 



18 Lea Brothers & Co.'s Publications — Pathology, Bacteriology. 



GIBBES, HEJSEAGE, M. !>., 

Professor of Pathology in the University of Michigan, Medical Department. 

Practical Pathology and Morbid Histology. In one very handsome octavo 
volume of 314 pages, with 60 illustrations, mostly photographic. Ciotb, $2.75. 

This is, in part, an expansion of the little work The work is throughout profusely illustrated with 



published by the author some years ago, and his 
acknowledged skill as a practical microscopist will 
give weighTt to his instructions. Indeed, in ful- 
ness of directions as to the modes of investigating 
morbid tissues the book leaves little to be desired. 



reproductions of micro-photographs. We may 
say that trie practical histologist will gain much 
useful information from the book. — The London 
Lancet, January 23, 1S92. 



ABBOTT, A. C, M.B., 

First Assistant, Laboratory of Hygiene, University of Penna., Philadelphia. 
The Principles of Bacteriology : a Practical Manual for Students and Physi- 
cians. In one 12mo. volume of 259 pages with 32 illustrations. Cloth, $2. Just ready. 

evidence of the originality of the author, as well 



During the last decade numerous works on this 
subject have been brought before the profession; 
yet, while many of them are exhaustive treatises, 
much of the laboratory technique requisite to the 
needs of beginners was emitted or most scantily 
treated On reading this manual of Dr. Abbott, 
any one familiar with the subject will readily 
recognize the fact that the book is not merely a 
compilation from other works, but one giving 



as complete knowledge of the practical details of 
bacteriology His "scheme for the study of an 
organism"" furnishes an excellent guide" to the 
student. Of equal importance is the chapter on 
disinfectants, antiseptics and skin disinfection. 
It will form a valuable addition to the literature 
of laboratory technique and bacteriological inves- 
tigation. — The Therapeutic Gazette, May" 16, 1S92. 



8JSNIT, NICHOLAS, M.I>., Ph.D., 

Professor of Surgery in Push Medical College, Chicago. 
Surgical Bacteriology. Jsew (second) edition. In one handsome octavo of 
26S pages, with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2. 

The book is really a systematic collection in the ' makes it possible for the busy practitioner, whose 
most concise form bf such results as are published 
in current medical literature by the ablest workers 
in this field of surgical progress ; and to these are 
added the author's own views and the results of 
his clinical experience and original investigations. 
The book is valuable to the student, but its chief 
value lies in the fact that such a compilation 



time for reading is limited and whose sources of 
information are often few, to become conversant 
with the most modern and advanced ideas in sur- 
gical pathology, which have "laid the foundation 
for the wonderful achievements of modern sur- 
gery.'' — Annals of Surgery, March, 1892. 



GBEEN, T. HENBY, M. !>., 

Lecturer on Pathology and Morbid Anatotny at Charing-Cross Hospital Medical School, London. 

Pathology and Morbid Anatomy. Sixth American from the seventh revised 

English edition. Octavo, 539 pp., with 167 engravings. Cloth, £2.75. 

The Pathology and Morbid Anatomy of Dr. translated into English, are too abstruse for the 
Green is too well" known by members of the medi- physician. Dr. Green's work precisely meets his 
cal profession to need any commendation. There wishes. The cuts exhibit the appearances of 



is scarcely an intelligent physician anywhere who 
has not the work in his library, for it is almost an 
essential. In fact it is better adapted to the wants 
of general practitioners than any work cf the kind 
with which we are acquainted. The works of 
German authors upon pathology, which have been 



pathological structures just as they are seen 
through the microscope. The fact that it is so 
generally employed as a text-book by medical stu- 
dents is" evidence that we have not spoken too 
much in its favor. — Cincinnati Medical yews, Oct. 
1S89. 



PAYNE, JOSEPH E., M. !>., E. B. C. P., 

Senior Assistant Physician and Lecturer on Pathological Anatomy , St. Thomas' Hospital, London. 
A Manual of General Pathology. Designed as an Introduction to the Prac- 
tice of Medicine. Octavo of 524 pages, with 152 illus. and a colored plate. Cloth, $3.50. 

cal factors in those diseases now with reasonable 



Knowing, as a teacher and examiner, the exact 
needs of medical students, the author has in the 
work before us prepared for their especial use 
what we do not hesitate to say is the best introduc- 
tion to general pathology that we have yet ex- 
amined. A departure which our author has 
taken is the greater attention paid to the causa- 
tion of disease, and more especially to the etiologi- 



certainty ascribed to pathogenetic microbes. In 
this department he has beehVery full and explicit, 
not only in a descriptive manner, but in the tech- 
nique of investigation. The Appendix, giving 
methods of research, is alone worth tne price of the 
book, several times over, to every student of 
pathology.— Si. Louis Med. and Surg. Jour., Jan. '89. 



COATS, JOSEPH, M. !>., F. F. P. S., 

Pathologist to the Glasgow Western Infirmary. 
A Treatise on Pathology. In one very handsome octavo volume of 829 pages, 
with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. 

Medical students as well as physicians, who manner, the changes from a normal condition 
desire a work for study or reference, that treats effected in structures by disease, and points out 
the subjects in the various departments in a very the characteristics of various morbid agencies, 
thorough manner, but without prolixity, will cef- so that they can be easily recognized. But, not 
tainly give this one the preference to any with limited to morbid anatomy, it explains fully how 
which we are acquainted. It sets forth the most the functions of organs are'disturbed by abnormal 
recent discoveries, exhibits, in an interesting conditions.— Cincinnati Medical Xeics, Oct. 1883. 



Lea Brothers & Co.'s Publications — Nerv. and Ment. Dis., etc. 19 



GRAY, LANDOJST CARTER, M. 2>., 

Professor of Diseases of the Mind and Nervous System in the New York Polyclinic. 

A Practical Treatise on Nervous and Mental Diseases. Shortly. 

This work is devoted purely to the practical aspects of nervous and mental diseases, 
especial care being taken to prepent the fundamental knowledge essential to a grasp of its 
subjects and to cast everything in the clearest possible form. The series of illustrations 
is rich and unique, embracing a large number of photographic engravings of exceptional 
vividness and interest. By the employment of a style at once concise and clear, and by 
careful arrangement, the author is enabled to include an exposition of a vast and important 
subject in a condensed and convenient form. 

ROSS, JAMBS, M. I)., F. R. C. P., LL. JO., 

Senior Assistant Physician to the Manchester Royal Infirmary. 

A Handbook on Diseases of the Nervous System. 

volume of 725 pages, with 184 illustrations. Cloth, $4.50 ; leather, $5.50. 



In one octavo 



The author has rendered a great service to the 
profession by condensing into one volume the 
principal facts pertaining to neurology and nerv- 
ous diseases as understood at the present time, 
and he has succeeded in producing a work at once 
brief and practical yet scientific, without entering 
into the discussion of theorists, or burdening the 
mind with mooted questions. — Pacific Medical and 
Surgical Journal and Western Lancet, May, 1886. 

This admirable work is intended for students of 
medicine and for such medical men as have no time 
for lengthy treatises. In the present instance the 
duty of arranging the vast store of material at the 



disposal of the author, and of abridging the de- 
scription of the different aspects of nervous dis- 
eases, has been performed with singular skill, and 
the result is a concise and philosophical guide to 
the department of medicine of which it treats. 
Dr. Ross holds such a high scientific position that 
any writings which bear his name are naturally 
expected to have the impress of a poweriui intel- 
lect. In every part this handbook merits the 
highest praise, and will no doubt be found of the 
greatest value to the student as well as to the prac- 
titioner. — Edinburgh Medical Journal, Jan. 1887. 



HAMILTON, ALLAN McLANE, M. J)., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackwelVs Island, N. Y. 
Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 
revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4. 



When the first edition of this good book appeared 
we gave it our emphatic endorsement, and the 
present edition enhances our appreciation of the 
book and its author as a safe guide to students of 
clinical neurology. One of the best and most 
critical of English neurological journals, Brain, has 



characterized this book as the best of its kind in 
any language, which is a handsome endorsement 
from an exalted source. The improvements in the 
new edition, and the additions to it, will justify its 
purchase even by those who possess the old. — 
Alienist and Neurologist, April, 1882. 



TUKE, DANIEL HACK, M. I)., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imagination. New edition. 
Thoroughly revised and rewritten. In one 8vo. vol. of 467 pp., with 2 col. plates. Cloth, $3. 



It is impossible to peruse these interesting chap- 
ters without being convinced of the author's per- 
fect sincerity, impartiality, and thorough mental 
grasp. Dr. Tuke has exhibited the requisite 
amount of scientific address on all occasions, and 
the more intricate the phenomena the more firmly 
has he adhered to a physiological and rational 



method of interpretation. Guided by an enlight- 
ened deduction, the author has reclaimed for 
science a most interesting domain in psychology, 
previously abandoned to charlatans and empirics. 
This book, well conceived and well written, must 
commend itself to every thoughtful understand- 
ing. — New York Medical Journal, September 6, 1884. 



C» St, 



CLOUSTON, THOMAS S., M. L>., F. R. C. P., L. R. 

Lecturer on Mental Diseases in the University of Edinburgh. 

Clinical Lectures on Mental Diseases. With an Appendix, containing an 
Abstract of the Statutes of the United States and of the Several States and Territories re- 
lating to the Custody of the Insane. By Charles F. Folsom, M. D., Assistant Professor 
of Mental Diseases, Med. Dep. of Harvard Univ. In one handsome octavo volume of 541 
pages, with eight lithographic plates, four of which are beautifully colored. Cloth, $4. 

J&g^Dr. Folsom's Abstract may also be obtained separately in one octavo volume of 
108 pages. Cloth, $1.50. 

SAVAGE, GEORGE H., M. D., 

Lecturer on Mental Diseases at Ghuy's Hospital, London. 

Insanity and Allied Neuroses, Practical and Clinical. In one 12mo. vol. 
of 551 pages, with 18 illus. Cloth, $2.00. See Series of Clinical Manuals, page 31. 

As a handbook, a guide to the practitioner and 
student, the book fulfils an admirable purpose. 
The many forms of insanity are described with 
characteristic clearness, the illustrative cases are 



carefully selected, and as regards treatment sound 
common sense is everywhere apparent. Dr. Sav- 
age has written an excellent manual for the prac- 
titioner and student. — Amer. Jour, oflnsan., Apr.'85. 



PLAYFAIR, W. S., M. D., F. R. C. P. 

The Systematic Treatment of Nerve Prostration and Hysteria. 

one handsome small 12mo. volume of 97 pages. Cloth, $1.00. 



In 



BLANDFORD ON INSANITY AND ITS TREAT- 
MENT. Lectures on the Treatment, Medical 
and Legal, of Insane Patients. In one very hand- 
some octavo volume. 



JONES' CLINICAL OBSERVATIONS ON FUNC- 
TIONAL NERVOUS DISORDERS. Second 
American Edition. In one handsome octavo 
volume of 340 pages. Cloth, $3.25 



20 Lea Brothers A Co.'s Publications — Surgery. 

BOBEBTS, JOHX B.. 31. D.. 

P 'omen and Surgery in the Philadelphia Polyclinic Professor of the Principle* and 

Praet- ■ Woman's Medical College c? Perin.it'.. -': ymy in the' D 

The Principles and Practice of Modern Surgery. For the use of Students 
and Practitioners of Medicine and Surgery. In one very handsome octavo volume of 750 
pages, with 501 illustrations. Cloth. $4.50; leather. > 5." 

This work is a very comprehensive manual upon vaneed doctrines and methods of practice 
genera - :.- ill doubtless meet with a prat general arrangement follows 



favorable reception by the profession. It ha* a this rule, and the author in his desire to be con- 
thoroughly practical character, th~ -e and practical is at times almost dogmatic, but 
treated with rare judgment, its conclusions are in this is entirely excusable considering the admira- 
accord r leading practitioners of ble manner in which he has thus increased the 
the ar:. erature is fuily up to &l\ the ad- usefulness of his work.— Med. Ree^ Jan. 17, 1891. 



ASBLBTCBST. JOEOT. Jr., 31. E>., 

1-. :: '. ?■■;;. ; -' i ;-: - ■. -'■".' : : •. V J ., Surgeon to 

The Principles and Practice of Surgery. Fifth edition, enlarged and 
thoroughly revised. In one large and handsome octavo volume of 11-44 pages, with 
642 illustrations. Cloth. $6 : leather. |7. 

A complete and most exceller.: work m surgery, every advance in surgery worth noting is to be 
I: is :r_':y necessary to examine it to see at once found in its proper r ace [tie unquestionably the 
fe exeellenee and "real merit either as text-book best and most complete single volume on surgery, 
for the student or a guide for the general practi- in the English language, and cannot but re 
tioner. It fully considers in detail every surgical that continued appreciation which its merit- 
:i ■•.;.—.■ :.-i disease :: •-;.::/- :r.e : : iy is iiar.ie7a=.i ier:;^r. i.— .; : -. '-.' . Practitioner, re':. UNI 



BBELTT, BOBEBT. 31. B. C. 8., etc. 

Manual of Modern Surgery. Twelfth edition, thoroughly revised by Stan- 
lzy Boyd. M. £.. E. S., F. E. C. S. In one Svo. volume of 965 pages, with 373 "illustra- 
tions. Cloth. $4 : leather. £5. 

Drain's Baig e i ' j has been an exceedingly popu- appreciated that a copy was issued by the Govern- 
lar work in the profession. It is stated thai 50,000 ment to each surgeon." The present edition, while 
. been mid in England, while in the it has I - peculiar to the work a: 

United State*, ever -ir.ee its Srst issue, it has been first, embodies ill recent disc* rrgery, 

used as a text-book to a very large extent. Dur- and is fully up to the times.— Cincinnati Medical 
ing the late war in this country it was so highly Xews, September, 1887. 

Gi3T, FBEDEBLCK JAMES. F. B. C. S., 

Senior Surgeon to the Royal Free Hospital, London. 

The Student's Surgery. A M%H . in Parte. In one square octavo volume 

of ?4r pages, with 159 engravings. Cloth, $3.7& 

GROSS. S. L)., 31. L>., LL. D., L>. C. L. Oxon., LL. F>. 

Cantab., 

Bme^ r^rgery in the Jefferson Medical College of Philadelphia. 

A System of Surgery: Pathological, Diag: Lenpeatk and Operative. 

Sixth edition, thoroughly revised and greatly improved. In two large and beautifully 
printed imperial octavo volumes containing 23S2 pages, illustrated by lo23 engravings. 
Strongly bound in leather, raised bands. $15: very handsome half Russia. $16. 

BALL, CBABLES B., 31. Ch. 9 Bub.. F. B. C. S., E. 9 

S -;-:. ■'■ n .-.i ^i'-.'i- ■?.: i':~ P. ' . ' 

Diseases of the Rectum and Anus. In one 12mo. volume of 417 pp., 
with 54 cuts, and 4 colored plates. Cloth. $2.25. See Stria of Clinical Manuals 31. 

TOVSG, JA3LES K., 31. L>„ 

■-■.ictor in Orihopwdic Surgery, Unite- \ a, Philadelphia, 

A Manual of Orthopaedic Surgery. Suitable for Students and Prac- 
titioners, in one 12ma volume of about ly illustrated. Preparing. 

BETLLX, HEXBY T., F. B. C.JSL, 

Assistant Surgeon to St. Bartholomew's Hospital, London. 

Diseases of the Tongue. In one 12mo. volume of 456 pages, with b colored 
plates and 3 woodcuts. Cloth, | Series of Clinical Manuals, :page 31. 

GOULD. A. BEABCE, 31. S., 31. B., F. B. C. S., 

Assistant Surgeon to Middlesex Hospital 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 5S9 
See Shtdcntt? Seria of Manuals, page 

PIRRIES PRINCIPLES AND PRACTICE OF one Svo. vol. of ^5 pages, with 340 Illustrations. 

BUBGEBT. Eiited bv John Nelll, M. D. In Cloth. $3.75. 

one8vo. toI. of 7*4 pp. w'ith 316 illus. Cloth, $3.75. MILLER'S PRACTICE OF SURGERY. Fourth 

MILLER"S PRINCIPLES OF SURGERY. Fourth and revised American edition. In one large Svo. 

American from the third Edinburgh edition. In voL of 682 pp., with 364 Illustrations, Cloth 43.75. 



Lea Brothers & Co.'s Publications — Surgery. 



21 



EBICH8EN, JOHN E., F. B. 8., F. B. C. 8., 

Professor of Surgery in University College, London, etc. 
The Science and Art of Surgery ; Being a Treatise on Surgical Injuries, Dis- 
eases and Operations. From the eighth and enlarged English edition. In two large 8vo. 
volumes of 2316 pages, with 984 engravings on wood. Cloth, $9; leather, $11. 

For many years this classic work has been 
made by preference of teachers the principal 
text-book on surgery for medical students, while 



through translations into the leading continental 
languages it may be said to guide the surgical 
teachings of the civilized world. No excellence 



of the former edition has been dropped and no 
discovery, device or improvement which has 
marked the progress of surgery during the last 
decade has been omitted. The illustrations are 
many and executed in the highest style of art. 
— Louisville Medical News, Feb. 14, 1885. 



BBYANT, THOMA8, F. B. C. S., 

Surgeon and Lecturer on Surgery at Guy's Hospital, London. 
The Practice of Surgery. Fourth American from the fourth and revised Eng- 
lish edition. In one large and very handsome imperial octavo volume of 1040 pages, with 
727 illustrations. Cloth, $6.50; leather, $7.50. 

The fourth edition of this work is fully abreast 
of the times. The author handles his subjects 
with that degree of judgment and skill which is 
attained by years of patient toil and varied ex- 
perience. The present edition is a thorough re- 



vision of those which preceded it, with much new 
matter added. His diction is so graceful and 
logical, and his explanations are so lucid, as to 



place the work among the highest order of text- 
books for the medical student. Almost every 
topic in surgery is presented in such a form as to 
enable the busy practitioner to review any subject 
in every-day practice in a short time. No time is 
lost with useless theories or superfluous verbiage. 
In short, the work is eminently clear, logical and 
practical.-C7MC«<70 Med. Jour, and Examiner, Apr. '86. 



WHABTON, MEN BY B., M. JD. 9 

Demonstrator of Surgery and Lecturer on Surgical Diseases oj Children in the Univ. of Penna. 

Minor Surgery and Bandaging. In one very handsome 12mo. volume of 
498 pages, with 403 engravings, many being photographic. Cloth, $3.00. 

rious established operations are described in detail. 
Hence this work becomes a most valuable compan- 
ion-book to any of the more pretentious treatises 
on surgery, where simply the general advice is 



This new work must take a first rank as soon as 
examined. Bandaging is well described by words, 
and th9 methods are illustrated by photographic 
drawings, so as to make plain each step taken in 
the application of bandages of various kinds to dif- 
ferent parts of the body and extremities— including 
the head. The various operations are likewise de- 
scribed and illustrated, so that it would seem easy 
for the tyro to do the gravest amputation. The va- 



given to bandage, amputate, intubate, operate, etc. 
For the student and young surgeon, it is a very 
valuable instruction book from which to learn how 
to do what may be advised, in general terms, to be 
done.— Virginia Medical Monthly, October 1891. 



TBEVE8, FBEJDEBICK, F. B. C. 8., 

Surgeon and Lecturer on Anatomy at the London Hospital. 

A Manual of Operative Surgery. In two octavo volumes containing 1550 
pages, with 422 original engravings Complete work, cloth, $9; leather, $11. Just ready. 

Mr. Treves in this admirable manual of opera- 
tive surgery has in each instance practically 
assumed that operation has been decided upon 



and has then proceeded to give the various opera- 
tive methods which may be employed, with a 
criticism of their comparative value and a detailed 
and careful description of each particular stage 
of their performance. Especial attention has been 
paid to the preparatory treatment of the patient 
and to the details of the after treatment of the 
case, and this is one of the most distinctive among 
the many excellent features of the book. We have 
no hesitation in declaring it the best work on the 
subject in the English language, and indeed, in 
many respects, the best in any language. It can- 



not fail to be of the greatest use both to practical 
surgeons and to those general practitioners who, 
owing to their isolation or to other circumstances, 
are forced to do much of theirown operative work. 
We feel called upon to recommend the book so 
strongly for the excellent judgment displayed in 
the arduous task of selecting from among the 
thousands of varying procedures those most 
worthy of description ; for the way in which the 
still more difficult task of choosing among the 
best of those has been accomplished; and for the 
simple, clear, straightforward manner in which 
the information thus gathered from all surgical 
literature ha3 been conveyed to the reader. — 
Annals of Surgery, March, 1892. 



By the Same Author. 
The Student's Handbook of Surgical Operations. In one square 12mo. 
volume of 508 pages, with 94 illustrations. Cloth, $2.50. Just ready. 

A Manual of Surgery. In Treatises by Various Authors, edited by Treves. 
In three 12mo. volumes, containing 1866 pages, with 213 engravings. Price per set, 
cloth, $6. See Students' Series of Manuals, page 30. 

We have here the opinions of thirty-three 
authors, in an encyclopedic form for easy and 
ready reference. The three volumes embrace 
every variety of surgical affections likely to be 
met with, the paragraphs are short and pithy, and 



the salient points and the beginnings of new sub- 
jects are always printed in extra-heavy type, so 
that a person may find whatever information he 
may be in need of at a moment's glance. — Cin- 
cinnati Lancet-Clinic, August 21, 1886. 



Intestinal Obstruction. In one pocket-size 12mo. volume of 522 pages, with 60 
illustrations. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 31. 



HOLME8, TIMOTHY, M. A., 

Surgeon arid Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery ; Theoretical and Practical. IN TKEATISES BY 
VARIOUS AUTHORS. American edition, thoroughly revised and re-edited 
by John H. Packard, M. D., Surgeon to the Episcopal Hospital, Philadelphia, assisted 
by a corps of thirty-three of the most eminent American surgeons In three large octavo 
volumes containing 3137 pages, with 979 illustrations on wood and 13 lithographic plates. 
Price per set, cloth, $18.00; leather, $21.00. Sold only by subscription. 



22 Lea Brothers & Co.'s Publications — Surgery , Frac., Disloc. 



SMITH, STEFHEX, M. H., 

Professor of Clinical Surgery in the University of the City of New York. 

The' Principles and Practice of Operative Surgery. Second and 
thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 
1005 illustrations. Cloth, $4.00; leather, '$5.00. 

This excellent and Tery valuable book is one of operative work. It can be truly said that as ahand- 
the most satisfactory works on modern operative book for the student, acompanion forthe surgeon, 
surgery yet published. Its author and publisher and even as a book of reference for the physician 
have spared no pains to make it as far as possible not especially engaged in the practice of surgery, 
an ideal, and their efforts have given it a position this volume will long hold a most conspicuous 
prominent among the receDt works in this depart- place, and seldom will its readers, no matter how 
ment of surgery. The book is a compendium for unusual the subject, consult its pages in vain. Its 
the modern surgeon. The present edition is much compact form, excellent print, numerous illustra- 
enlarged, and the text has been thoroughly revised, tions, and especially its decidedly practical char- 
so as to give the most improved methods in asep- acter, all combine to commend it. — Boston Medical 
tic surgery, and the latest instruments known for ; and Surgical Journal, May 10, 1888. 

HOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A Treatise on Surgery ; Its Principles and Practice. From the fifth 
English edition, edited by T. Pickering Pick, F. E. C. S. In one octavo volume of 997 
pages, with 428 illustrations. Cloth, $6.00 ; leather, $7.00. 

To the younger members of the profession and 
to others "not acquainted with the book and its 



merits, we take pleasure in recommending it as a 
surgery complete, thorough, well-written, fully 
illustrated, modern, a work sufficiently volumi- 
nous for the surgeon specialist, adequately concise 



for the general practitioner, teaching those things 
that are necessary to be known for the successful 
prosecution of the physician's career, imparting 
nothing that in our present knowledge is consid- 
ered unsafe, unscientific or inexpedient. — Pacific 
Medical Journal, July, 1889. 



HAMHTOjT, FBAJTK H., M. JD., II. 2>., 

Surgeon to BeUevue Hospital, New York. 

A Practical Treatise on Fractures and Dislocations, Xew (8th) edi- 
tion, revised and edited by Stephen Smith, A. M., M. D., Professor of Clinical Surgery 
in the University of the City of Xew York. In one very handsome octavo volume of 832 
pages, with 507 'illustrations. Cloth, $5.50 ; leather, $6.50. 
The work of Dr. Hamilton is so well known that ject of such magnitude is no easy one. Dr. Smith 



a description is almost unnecessary. Its numer- 
ous editions are convincing proof if any is needed, 
of its value and popularity. It is pre eminently 
the authority on fractures and dislocations, and 
universally quoted as such. In the new edition it 
has lost none of its former worth. The additions 
it has received by its recent revision make it a 
work thoroughly in accordance with modern 
practice, theoretically, mechanica^y. aseptically. 
The task of writing a complete treatise on a sub- 



has aimed to make the present volume a correct 
exponent of our knowledge of this department 
of surgery. In examining the volume one is at 
once struck with the evidence of the vast amount 
of labor its compilation and reconstruction must 
have necessitated. The more one reads the more 
one is impressed with its completeness. The work 
has been accomplished, and has been done clearly, 
conciselv, excellently well.— Boston Medical and 
Suraical Journal. May 26, 1892. 



STIMSOIT, IEWIS A., B. A., M. H., 

Professor of Clinical Surgery in the Medical Faculty of Univ. of # City of N. Y., 

A Manual of Operative Surgery. Second edition. In one very handsome 

royal 12mo. volume of 503 pages, with 342 illustrations. Cloth, $2.50. 
There is always room for a good book, so that effected in operative methods and procedures by 



while many works on operative surgery must be 
considered superfluous, that of Dr. Stimson has 
held its own. The author knows the' difficult art 
of condensation. Thus the manual serves as a 
work of reference, and at the same time as a 
handy guide. It teaches what it professe?, the 
steps of operations. In this edition Dr. Stimson 
has sought to indicate the changes that have been 



the antiseptic system, and has added an account 
of many new operations and variations in the 
steps of older operations. We do not desire to 
extol this manual above many excellent standard 
British publications of the same class, still we be- 
lieve that it contains much that is worthy of imi- 
tation.— British Medical Journal, Jan. 22, 1887. 



By the same Author. 
A Treatise on Fractures and Dislocations. In two handsome octavo vol- 
umes. Vol. I., Fractures, 582 pages, 360 beautiful illustrations. Vol. II., Disloca- 
tions, 540 pages, with 163 illustrations. Complete work, cloth, $5.50 ; leather, $7.50. 
Either volume separately, cloth, $3.00 ; leather, $4.00. 
The appearance of the second volume marks the of Dislocations as it is taught and practised by the 



completion of the author's original plan of prepar- 
ing a work which should present in the fullest 
manner all that is known on the cognate subjects 
of Fractures and Dislocations. The volume on 
Fractures assumed at once the position of authority 
on the subject, and its companion on Dislocations 
will no doubt be similarly received. The closing 
volume of Dr. Stimson's work exhibits the surgery 



most eminent surgeons of the present time. Con- 
taining the results of such extended researches it 
must for a long time be regarded as an authority 
on all subjects pertaining to dislocations. Every 

Sractitioner of surgery will feel it incumbent on 
im to have it for constant reference.— Cincinnati 
Medical News, May, 1888. 



PICK, T. PICKERING, F. B. C. S., 

Surgeon to and Lecturer on Surgery at St. George's Hospital, London, 

Fractures and Dislocations. In one 12mo. volume of 530 pages, with 93 
illustrations. Limp cloth, $2.00. See Series of Ginical Manuals, page 31. 

MABSH, HOWARD, F. B. C. S., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St Bartholomew's Hospital, London, 
Diseases of the Joints. In one 12mo. volume of 468 pages, with 64 woodcuts 
and a colored plate. Cloth, $2.00. See Series of Ginical Manuals, page 31. 



Lea Brothers & Co.'s Publications — Otology, Ophthalmology. 23 



BVBWETT, CSABLE8 H,, A. M., M. I)., 

Professor of Otology in the Philadelphia Polyclinic ; President of the American Otological Society. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. Second edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. 

carried out, and much new matter added. Dr. 
Burnett's work must be regarded as a very valua- 
ble contribution to aural surgery, not only on 
account of its comprehensiveness, but because it 
contains the results of the careful personal observa- 
tion and experience of this eminent aural surgeon. 
— London Lancet, Feb. 21, 1885. 



We note with pleasure the appearance of a second 
edition of this valuable work. When it first came 
out it was accepted by the profession as one of 
the standard works on modern aural surgery in 
the English language; and in his second edition 
Dr. Burnett has fully maintained his reputation, 
for the book is replete with valuable information 
and suggestions. The revision has been carefully 



BEBBY, GEOBGE A., M. B., F. B. C. 8., Ed., 

Ophthalmic Surgeon, Edinburgh Royal Infirmary. 

Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. New 
(second) edition. In one octavo volume of about 700 pages, with about 150 illustrations, 
62 of which are beautifully colored. Preparing. 

A notice of the previous edition is appended. 



This newest candidate for favor among ophthal- 
mological students is designed to be purely clinical 
in character and the plan is well adhered to. We 
have been forcibly struck by the rare good taste 
in the selection of what is essential which per- 
vades the book. The author seems to have the 
uncommon faculty of viewing his subject as a 
whole and seizing the salient points and not con- 
fusing his reader — presumably a student and a 



novice — with a mass of details with no key to their 
unravelling. It is apparent that the literature of 
each subject has been gone over in a very thor- 
ough manner. The fact that he was writing a 
clinical treatise for beginners and not an encyclo- 
paedia has always been present with the author. 
The number and excellence of the colored illus- 
trations in the text deserve more than a passing 
notice. — Archives of Ophthalmology, Sept. 1889. 



NETTLE8SIJP, EDWARD, E. B. C. 8., 

Ophthalmic Surgeon at St. Thomas'" Hospital, London. Surgeon to the Royal London (Moorfields) 
Ophthalmic Hospital. 

Diseases of the Eye. Fourth American from the fifth English edition, thor- 
oughly revised. With a Supplement on the Detection of Color Blindness, by Wil- 
liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College. 
In one 12mo. volume of 500 pages, with 164 illustrations, selections from Snellen's test- 
types and formulae, and a colored plate. Cloth, $2.00. 
This is a well-known and a valuable work. It 



was primarily intended for the use of students, 
and supplies their needs admirably, but it is as 
useful for the practitioner, or indeed more so. It 
does not presuppose the large amount of recondite 
knowledge to be present which seems to be as- 
sumed in some of our larger works, is not tedious 
from over- conciseness, and yet covers the more 



important parts of clinical ophthalmology. A 
supplement is made to the present edition on the 
practical examination of railroad employes as to 
color-blindness and acuteness of vision and hear- 
ing. This is well written, and contains good 
suggestions for those who may be called on to 
make such examinations. — JSew York Medical 
Journal, December 13, 1890. 



JJJLEB, SEJSTBY E., E. B. C. 8., 

Senior AssH Surgeon, Royal Westminster Ophthalmic Hosp.; late Clinical Ass't, Moorfields, London. 

A Handbook of Ophthalmic Science and Practice. English Edition. 
Handsome 8vo. volume of 442 pages, with 125 woodcuts, 27 colored plates, selec- 
tions from Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. 
Cloth, $5.50 ; leather, $6.50. 

It presents to the student concise descriptions illustrations are nearly all original. We have ex- 
and typical illustrations of all important eye affec- amined this entire work with great care, and it 
tions, placed in juxtaposition, so as to be grasped represents the commonly accepted views of ad- 
at a glance. Beyond a doubt it is the best illus- vanced ophthalmologists. We can most heartily 
trated handbook of ophthalmic science which has commend this book to all medical students, prac- 
ever appeared. Then, what is still better, these titioners and specialists.— Detroit Lancet, Jan. '85. 



NOBBI8, W31. F., M. D., and OLIVEB, CHA8. A., M. D< 



Clin. Prof, of Ophthalmology in Univ. of Pa. 

A Text-Book of Ophthalmology. 

with illustrations. In 



In one octavo volume of about 800 pages, 



CABTEB, B. BBTJDENELL, & FB08T, W.ADAM8, 

F. B. C. 8., F. B. C. 8., 

Ophthalmic Surgeon to and Led. on Ophthal- Ass't Ophthalmic Surgeon and Joint Led. 

mic Surgery at St. George's Hospital, London. on Oph. Sur., S/t. George's Hosp., London. 

Ophthalmic Surgery. In one 12mo. volume of 559 pages, with 91 woodcuts, 
color-blindness test, test-types and dots and appendix of formulas. Cloth, $2.25. See 
Series of Clinical Manuals, page 31. 



WELLS ON THE EYE. In one octavo volume. 

LAURENCE AND MOON'S HANDY BOOK OF 
OPHTHALMIC SURGERY, for the use of Prac- 
titioners. Second edition. In one octavo vol- 
ume of 227 pages, with 65 illus. Cloth, $2.75. 



LAWSON ON INJURIES TO THE EYE, ORBIT 
AND EYELIDS: Their Immediate and Remote 
Effects. In one octavo volume of 404 pages, with 
92 illustrations. Cloth, 83.50. 



24 Lea Brothers & Co.'s Publications — Urin. Dis., Dentistry, etc. 
ROBERTS, SIR WILLIAM, M. 2>., 

Lecturer on Medicine in the Manchester School of Medicine, etc, 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In one hand- 
some octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. 

It may be said to be the best book in print on the a completeness not found elsewhere in our lan- 
subject of which it treats. — The American Journal euage m its account of the different affections.— 
of the Medical Sciences, Jan. 1886. The Manchester Medical Chronicle, July, 1885. 

The peculiar value and finish of the book are in The value of this treatise as a guide book to the 
a measure derived from its resolute maintenance physician in daily practice can hardly be over- 
of a clinical and practical character. It is an un- estimated. That it is fully up to the level of our 
rivalled exposition of everything which relates present knowledge is a fact reflecting great credit 
directlv or indirectly to the diagnosis, prognosis upon Dr. Roberts, who has a wide reputation as a 
and tre'atment of urinary diseases, and possesses busy practitioner.— Medical Record, July 31, 1886. 

By the Same Author. 
Diet and Digestion. In one 12mo. volume of 270 pp. Cloth, $1.50. Just ready. 

FURDY, CHARLES W. 9 21. &., Chicago. 

Bright's Disease and Allied Affections of the Kidneys. In one octavo 

volume of 288 pages, with illustrations. Cloth, $2. 

The object of this work is to "furnish a system- short space the theories, facts and treatments, and 
atic, practical and concise description of the going more fully into their later developments, 
pathology and treatment of the chief organic On treatment the writer is particularly strong, 
diseases "of the kidney associated with albuminu- steering clear of generalities, and seldom omit- 
ria, which shall represent the most recent ad- ting, what text-books usually do, the unimportant 
vances in our knowledge on these subjects ; " and items which are all important to the general prac- 
this definition of the object is a fair description of titioner. — The Manchester Medical Chronicle, Oct. 
the book. The work is a useful one, giving in a 1886. 



MORRIS, HE1YRY, M. B., F. R. C. S., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London, 

Surgical Diseases of the Kidney. In one 12mo. volume of 554 pages, with 40 
woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, page 31. 
In this manual we have a distinct addition to he took in hand. It is a full and trustworthy 
surgical literature, which gives information not book of reference, both for students and prae- 
elsewhere to be met with in a single work. Such titioners in search of guidance. The illustrations 
a book was distinctly required, and Mr. Morris in the text and the chromo-lithographs are beau- 
has very diligently and ably performed the task tif ally executed. — The London Lancet, Feb. 26, 1386. 

LUCAS, CLEMEXT, M. B., B. S., E. R. C. S., 

Senior Assistani Surgeon to Guy's Hospital, London, 

Diseases of the Urethra. In one 12mo. volume. Preparing. See Series 
of Clinical Manuals, page 4. 

THOMFSOS, SIR KEXRY, 

Surgeon and Professor of Clinical Surgery to University College Hospital, London, 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulee. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

THE AMERICAX SYSTEM OF DEXTISTRY. 

In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., 
D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the 
Pennsylvania College of Dental Surgery. In three very handsome octavo volumes con- 
taining 3160 pages, with 1S63 illustrations and 9 full-page plates. Per volume, cloth, £6 ; 
leather, $7 ; half Morocco, gilt top, $3. The complete work is now ready. For sale by 
subscription only. 

As an encyclopaedia of Dentistry it has no su- doubtless it is), to mark an epoch in the history of 
perior. It should form a part of every dentist's dentistry. Dentists will be satisfied with it and 
library, as the information it contains is of the proud of it — they must. It is sure to be precisely 
greatest value to all engaged in the practice of what the student needs to put him and keep him 
dentistry. — American Jour. Dent. Sci., Sept. 1SS>3. in the right track, while the profession at large 

A grand system, big enough and good enough will receive incalculable benefit from it. — Odonto- 
and handsome enough for a monument (which graphic Journal, J &n. 1887. 

COLEMAJST, A., L. R. C. F., F. R. C. S., Exam. L. D. S., 

Senior Bent. Surg, and Lect. on Dent. Surg, at St. Bartholomew'' s Hosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Stellwages*, M. A., M. D., 
D. D. S., Prof, of Physiology in the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 

It should be in the possession of every practi- a work. If the money put into some of our so- 
tioner in this country. The part devoted to first called standard text-books could be converted into 
and second dentition "and irregularities in the per- such publications as this, much good would result. 
manent teeth is fully worth the price. In fact, — Southern Dental Journal, May, 1SS2. 
price should not be considered in purchasing such 

BASHAM 0>" RENAL DISEASES: A Clinical I one 12mo. vol. of 304 pages, with 21 Illustrations. 
Guide to their Diagnosis and Treatment. In | Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Dis. of Men, Venereal, Skin. 25 



GKOSS, SAMUEL W., A. M. 9 M. D. 9 LL. D. 9 

Professor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical College of Phila. 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. Fourth edition, thoroughly revised by F. R. 
Stukgis, M. D., Prof, of Diseases of the Genito-Urinary Organs and of Venereal Diseases, 
N. Y. Post Grad. Med. School. In one very handsome octavo volume of 165 pages, 
with 18 illustrations. Cloth, $1.50. 



Three editions of Professor Gross' valuable book 
have been exhausted, and still the demand is 
unsupplied. Dr. Siurgis has revised and added 
to the previous editions, and the new one appears 
more complete and more valuable than before. 
Four important and generally misunderstood sub- 
jects are treated— impotence, sterility, spermator- 



rhoea, and prostatorrhcea. The book is a practical 
one and in addition to the scientific and very in- 
teresting discussions on etiology, symptoms, etc., 
there are lines of treatment laid down that any 
practitioner can follow and which have met with 
success in the hands of author and editor.— Medi- 
cal Record, Feb. 25, 1891. 



TAYLOB, JR. W., A. M., M. Z>., 

Clinical Professor of Qenito- Urinary Diseases in the Colleqe of Physicians and Surgeons, New York, 
Prof, of Venereal and Skin Diseases in the University of Vermont. 

The Pathology and Treatment of Venereal Diseases. Including the 

results of recent investigations upon the subject. Being the sixth edition of Bumstead 

and Taylor. Entirely rewritten by Dr. Taylor. Large 8vo. volume, about 900 pages, 

with about 150 engravings, as well as numerous chromo-lithographs. In active preparation. 

A notice of the previous edition is appended. 

upon the subjects of which it treats, but also one 
which has no equal in other tongues for its clear, 



It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 



comprehensive and practical handling of its 
themes.— Am. Jour, of the Med. Sciences, Jan. 1884. 



CULVER, E. M., M.D., and HAYDEIT, J. M., M.B. 

Pathologist and Assistant Attending Surgeon, Chief of Clinic Venereal Department, Van- 

Manhattan Hospital, N. Y. derbilt Clinic, Co). ofPhys. and Surgs , N. Y. 

A Manual of Venereal Diseases. In one 12mo. volume of 289 pages, with 
33 illustrations. Cloth, $1.75. 



This book is a practical treatise, presenting in a 
condensed form the essential features of our pres- 
ent knowledge of the three venereal diseases, 
syphilis, chancroid and gonorrhea. We have ex- 
amined this work carefully and have come to the 
conclusion that it is the most concise, direct and 
able treatise that has appeared on the subject of 
venereal diseases for the general practitioner to 



adopt as a guide. The general practitioner needs 
a few simple, concise and clearly presented laws, 
in the execution of which he cannot fail either to 
cure or prevent the ravages of the maladies in 
question and the direful results which their pro- 
pagation entails.— Buffalo Medical and Surgical 
Journal, May, 1892. 



C/OBJWLLj V. f Prof, to the Faculty of Medicine of Paris, and Physician to the Lour cine Hosp. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Henry C. Simes, 
M. D., Demonstrator of Pathological Histology in the Univ. of Pa., and J. William 
White, M. D., Lecturer on Venereal Diseases, Univ. of Pa. In one handsome octavo 
volume of 461 pages, with 84 very beautiful illustrations. Cloth, $3.75. 



The anatomy, the histology, the pathology and 
the clinical features of syphilis are represented in 
this work in their best, most practical and most 
instructive form, and no one will rise from its 



perusal without the feeling that his grasp of the 
wide and important subject on which it treats is 
a stronger and surer one. — The London Practi- 
tioner, Jan. 1882. 



HUTCHINSON, JONATHAN, F. M. S., F. B. C. S., 

Consulting Surgeon to the London Hospital. 
Syphilis. In one 12mo. volume of 542 pages, with 8 chromo-lithographs. Cloth, 
$2.25. See Series of Clinical Manuals, page 31. 
Those who have seen most of the disease and I and power of observation, but of his patience and 



those who have felt the real difficulties of diagno- 
sis and treatment will most highly appreciate the 
facts and suggestions which abound in these 
pages. It is a worthy and valuable record, not 
only of Mr. Hutchinson's very large experience 



assiduity in taking notes of his cases and keep- 
ing them in a form available for such excellent 
use as he has put them to in this volume.— London 
Medical Record, Nov. 12, 1887. 



GBOSS, S. D., M. JD. 9 LL. &., D. C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
edition, thoroughly revised by Samuel W. Gross, M. D. In one octavo volume of 574 
pages, with 170 illustrations. Cloth, $4.50. 

PYE-SMITH, P. H., M. !>., F. B. 8., 

Physician to Guy's Hospital, London. 

A Handbook of Diseases of the Skin. By Philip H. Pye-Smith, M. D., 
F. E. S , Physician to Guy's Hospital, London. In one octavo volume of 450 pages, 
with illustrations. Preparing. 



HILLIER'S HANDBOOK OF SKIN DISEASES; 
for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, 
with plates. Cloth, $2.25. 

HILL ON SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. 

LEE'S LECTURES ON SYPHILIS AND SOME 



WILSON'S STUDENT'S BOOK OF CUTANEOUS 
MEDICINE AND DISEASES OF THE SKIN. 
In one handsome small octavo volume of 536 
pages. (. loth, $3.50. 
FORMS OF LOCAL DISEASE AFFECTING 
PRINCIPALLY THE ORGANS OF GENERA- 
TION. In one 8vo. vol. of 246 pages. Cloth, $2.25. 



26 Lea Brothers & Co.'s Publications — Venereal, Skin. 

TAYLOR, EGBERT W., A.M., M. 2>., 

Clinical Professor of Genifo- Urinaru Diseases in the College of Physicians and Surgeons, New York ; 
Surgeon to the "Department of Venereal and Skin Diseases of the JSew York Hospital; Presi- 
dent of the American Dermatological Association. 

A Clinical Atlas of Venereal and Skin Diseases: Including Diagnosis, 
Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and 
comprising 58 beautifully colored plates with 213 figures, and 431 pages of text with 85 
engravings. Complete work just ready. Price per part, $2.50. Bound in one volume, 
half Russia, $27 ; half Turkey Morocco, $28. For sale by subscription only. Specimen 
plates sent on receipt of 10 cents. A full prospectus sent to any address on application. 

It would be hard to use words which would per- student can examine these true-to-life chromo-lith- 
spicuously enough convey to the reader the great ographs. Comparing the text to a lecturer, it is 
value of this Clinical Atlas. This Atlas is more more satisfactory in exactness and fulness than 
complete even than an ordinary course of clinical he would be likely to be in lecturing over a single 
lectures, for in no one college or hospital course case. Indeed, this Atlas is invaluable to the gen- 
is it at all probable that all of the diseases herein eral practitioner, for it enables the eye of the 
represented would be seen. It is also more ser- physician to make diagnosis of a given case of 
viceable to the majority of students than attend- skin manifestation by comparing the case with 
ance upon clinical lectures, for most of the the picture in the Atlas, where will be found also 
students who sit on remote seals in the lecture the text of diagnosis, pathology, and full sections 
hall cannot see the subject as well as the office on treatment.— Virginia Medical Monthly, Dec. 1889. 



JACKSON, GEORGE THOMAS, M. D., 

Professor of Dermatology, Women's Meaical College, New York Infirmary. 

The Ready-Reference Handbook of Skin Diseases. In one 12mo. 
volume of 450 pages, with 50 illustrations. Cloth, $2.75. Just ready. 

This volume is devoted to the art of dermatology, to the practice of this department of 
medicine in its latest development. No attempt has been made to discuss debatable ques- 
tions, and pathology and etiology do not receive as full consideration as symptomatology, 
diagnosis and treatment. The alphabetical arrangement of the different diseases has been 
adopted as conducive to the greatest possible convenience in use. The pages are illus- 
trated with a large number of engravings, many being photographic and vivid reproduc- 
tions of actual cases. A handsome lithographic frontispiece adds to the beauty and 
usefulness of a volume for which a wide recognition is assured. 



JLARDAWAY, W. A., M. J>., 

Professor of Skin Diseases in the Missouri Medical College, St. Louis. 
Manual of Skin Diseases. With Special Reference to "Diagnosis and Treat- 
ment. For the use of Students and General Practitioners. 12mo., 440 pp. Cloth, $3. 

Dr. Hardaway's large experience as a teacher embraces all essential points connected with the 
and writer has admirably fitted him for the diffi- diagnosis and treatment of diseases of the skin, 
cult task of preparing a book which, while suffi- and we have no hesitation in commending it as 
ciently elementary for the student is yet suffi- the best manual that has yet appeared in this 
ciently thorough and comprehensive to serve as a department of Medicine.— Journal of Cutaneous 
book of reference for the general practitioner. It | and Genito- Urinary Diseases. 



JETYDE, J. NEVINS, A. M., M. JD., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. Second edition. In one handsome octavo volume of 676 pages, with 
2 colored plates and 85 beautiful and elaborate illustrations. Cloth, $4.50; leather, $5.50. 

His .treatise is like his clinical instruction, 
admirably arranged, attractive in diction, and 
strikingly practical throughout. No clearer de- 



scription of the various primary and consecutive 
lesions of the skin is to be met with anywhere. 
Dr. Hyde has shown himself a comprehensive 
reader of the latest literature, and has incorpo- 
rated into his book all the best of that which 



the past years have brought forth. The prescrip- 
tions and formula? are given in both common and 
metric systems. Text and illustrations are good, 
and colored plates of rare cases lend additional 
attractions. Altogether it is a work exactly fitted 
to the needs of a genera' practitioner, and no one 
will make a mistake in purchasing it.— Medical 
Press of Western New York, June, 1888. 



JAMIESON, W. ALLAN, M. 2>., 

Lecturer on Diseases of the Skin, School of Medicine, Edinburgh. 
Diseases of the Skin. A Manual for Students and Practitioners. Third 
edition, revised and enlarged. In one octavo volume of 656 pages, with woodcut and 
nine double-page chromo- lithographic illustrations. Cloth, $6.00. Just ready. 

In common with other special departments in I This volume by Dr. Jamieson is a valuable one for 
medicine, that of dermatology is rapidly approach- practitioners and students, as it is both full and 
ing an exactness in diagnosis and treatment which concise without being unwieldy and voluminous. — 
fairly places it at the front among the specialties. Tl\e Jour, of the Amer. Med. Asso., March 19, 1892. 



FOX, T., M. D., F.R. C. L>., and FOX, T. C, B.A., M.R. C.S., 

Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the 

University College Hospital, London. Westihinster Hospital, London. 

An Epitome of Skin Diseases. With Formulae. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one 12mo. vol. of 238 pp. Cloth, $1.25. 
We cordially recommend Fox's Epitome to those | for all one has to know is the name of the disease, 
whose time is limited and who wish a handy j and here are its description and the appropriate 
manual to lie upon the table for instant reference, j treatment at hand, ready for instant application. 
Its alphabetical arrangement is suited to this use, I 



Lba Brothers & Co.'s Publications — Dis. of Women, 



27 



The American Systems of Gynecology and Obstetrics. 

Systems of Gynecology and Obstetrics, in Treatises by American 
Authors. Gynecology edited by Matthew D. Mann, A. M., M. D., Professor of Obstetrics 
and Gynecology in the Medical Department of the University of Buffalo; and Obstet- 
rics edited by Barton Cooke Hirst, M. D., Associate Professor of Obstetrics in the 
University of Pennsylvania, Philadelphia. In four very handsome octavo volumes, con- 
taining 3612 pages, 1092 engravings and 8 plates. Complete work now ready. Per vol- 
ume: Cloth, $5.00; leather, $6.00; half Russia, $7.00. For sale by subscription only. 
Address the Publishers. Full descriptive circular free on application. 

LIST OF CONTRIBUTORS. 

HOWARD A. KELLY, M. D., 
CHARLES CARROLL LEE, M. D., 
WILLIAM T. LUSK, M. D., LL. D., 
J. HENDRIE LLOYD, M. D., 
MATTHEW D. MANN, A. M., M. D., 
H. NEWELL MARTIN, F. R. S., M. D., 
RICHARD B. MAURY, M. D., 
C. D. PALMER, M. D., 
ROSWELL PARK, M. D., 
THEOPHILUS PARVIN, M. D., LL. D., 
R. A. F. PENROSE, M. D., LL. D., 
THADDEUS A. REAMY, A. M., M. D., 
J. C. REEVE, M. D., 
A. D. ROCKWELL, A. M., M. D., 
ALEXANDER J. C. SKENE, M. D., 
J. LEWIS SMITH, M. D., 
STEPHEN SMITH, M. D., 
R. STANSBURY SUTTON, M. D., LL. D., 
T. GAILLARD THOMAS, M. D., LL. D., 
ELY VAN DE WARKER, M. D., 
W. GILL WYLIE, M. D. 
United States, the character of the soil, the man- 
ners and customs of the people, etc., it is pecul- 
iarly adapted to the wants of American practition- 
ers of medicine, and it seems to us that every one 
of them would desire to have it." Every word 
thus expressed in regard to the "American Sys- 
tem of Practical Medicine" is applicable to the 
"System of Gynecology by American Authors." 
It, like the other, has been written exclusively 
by American physicians who are acquainted with 
all the characteristics of American people, who are 
well informed in regard to the peculiarities of 
American women, their manners, customs, modes 
of living, etc. As every practising physician is 
called upon to treat diseases of females, and as 
they constitute a class to which the family phy- 
sician must give attention, and cannot pass over 
to a specialist, we do not know of a work in any 
department of medicine that we should so strongly 
recommend medical men generally purchasing. — 
Cincinnati Med. News, July, 1887. 



WILLIAM H. BAKER, M. D., 
ROBERT BATTEY, M. D.„ 
SAMUEL C. BUSEY, M. D., 
JAMES C. CAMERON, M. D., 
HENRY C. COE, A. M., M. D., 
EDWARD P. DAVIS, M. D., 
G. E. De SCHWEINITZ, M. D., 
E. C. DUDLEY, A. B., M. D., 
B. McE. EMMET, M. D., 
GEORGE J. ENGELMANN, M. D., 
HENRY J. GARRIGUES, A. M., M. D., 
WILLIAM GOODELL, A. M., M. D., 
EGBERT H. GRANDIN, A. M., M. D., 
SAMUEL W. GROSS, M. D., 
ROBERT P. HARRIS, M. D., 
GEORGE T. HARRISON, M. D., 
BARTON C. HIRST, M. D. 
STEPHEN Y. HOWELL, M. D., 
A. REEVES JACKSON, A. M., M. D., 
W. W. JAGGARD, M. D., 
EDWARD W. JENKS, M. D., LL. D., 
These volumes are the contributions of the most 
eminent gentlemen of this country in these de- 
partments of the profession. Each contributor pre- 
sents a monograph upon his special topic, so that 
everything in the way of history, theory, methods, 
and results is presented to our fullest need. As a 
work of general reference, it will be found remarka- 
bly full and instructive in every direction of 
inquiry. — The Obstetric Gazette, September, 1889. 

One is at a loss to know what to say of this vol- 
ume, for fear that just and merited praise may be 
mistaken for flattery. The papers of Drs. Engel- 
mann, Martin, Hirst, Jaggardand Reeve are incom- 
parably beyond anything that can be found in 
obstetrical works.— Journalofthe American Medical 
Association, Sept. 8, 1888. 

In our notice of the "System of Practical Medi- 
cine by American Authors," we made the follow- 
ing statement: — "It is a work of which the pro- 
fession in this country can feel proud. Written 
exclusively by American physicians who are ac- 
quainted with all the varieties of climate in the 



BMMJET, THOMAS ADDIS, M. D. 9 LL. D., 

Surgeon to the Woman's Hospital, New York, etc. 

The Principles and Practice of Gynaecology ; For the use of Students and 
Practitioners of Medicine. Third edition, thoroughly revised. In one large and very 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5 ; leather, $6. 



We are in doubt whether to congratulate the 
author more than the profession upon the appear- 
ance of the third edition of this well-known work. 
Embodying, as it does, the life-long experience of 
one who has conspicuously distinguished himself 
as a bold and successful operator, and who has 
devoted so much attention to the specialty, we 
feel sure the profession will not fail to appreciate 



the privilege thus offered' them of perusing the 
views and practice of the author. His earnestness 
of purpose and conscientiousness are manifest. 
He gives not only his individual experience but 
endeavors to represent the actual state of gyne- 
cological science and art. — British Medical Jour- 
nal, May 16, 1885. 



EDIS, ABTMUB W., M. D. 9 Lond., F.B. C.P., M.B. C.S., 

Assist. Obstetric Physi cian to Middlesex Hospital, late Physician to British Lying-in Hospital. 
The Diseases of Women. Including their Pathology, Causation, Symptoms, 
Diagnosis and Treatment. A Manual for Students and Practitioners. In one handsome 
octavo volume of 576 pages, with 148 illustrations. Cloth, $3.00 ; leather, $4.00. 



The special qualities which are conspicuous 
are thoroughness in covering the whole ground, 
clearness of description and conciseness of state- 
ment. Another marked feature of the book is 
the attention paid to the details of many minor 
surgical operations and procedures, as, for 
instance, the use of tents, application of leeches, 
and use of hot water injections. These are 



among the more common methods of treat- 
ment, and yet very little is said about them in 
many of the text-books. The book is one to be 
warmly recommended especially to students and 
general practitioners, who need a concise but com- 
plete risuml of the whole subject. Specialists, too, 
will find many useful hints in its pages.— Boston 
Med. and Surg. Journ., March 2, 1882. 



HODGE ON DISEASES PECULIAR TO WOMEN. 
Incl uding Displacements of the Uterus. Second 
edition, revised and enlarged. In one beauti- 
fully printed octavo volume of 519 pages, with 
original illustrations. Cloth, $4.50. 



WEST'S LECTURES ON THE DISEASES OP 
WOMEN Third American from the third Lon- 
don edition. In one octavo volume of 543 pages. 
Cloth, $3.75; leather, $4.75. 



28 



Lea Brothers & Co.'s Publications — Diseases of Women. 



THOMAS, T. GAILLABD, and MUNDE, PAUL F., 

M. D., LL. D., M. D., 

Emeritus Professor of Diseases of Women in the College Professor of Gynecology in the New York 

of Physicians and Surgeons, N. F. Polyclinic. 

A Practical Treatise on the Diseases of Women. New (sixth) edition, 
thoroughly revised and rewritten by Dr. Munde. In one large and handsome octavo 
volume of 824 pages, with 347 illustrations, of which 201 are new. Cloth, $5 ; leather, $6. 



Probably no treatise ever written by an Ameri- 
can author on a medical topic has been accepted 
by more practitioners, as a standard text-book, or 
read with pleasure and profit by more medical 
students than Thomas on the diseases of women. 
Next to the indescribable charm of listening to 
Dr. Thomas' lectures and clinics, which have in 
them the element of a captivating and inspiring 
personality— which must be heard and felt to be 
properly appreciated— is this volume, which in 
classic excellence, elegance of diction and scholar- 



ly and scientific statement must remain what it 
long has been, a standard text-book both for prac- 
titioner and student, at home and abroad, and an 
enduring pride to American gynecologists. In a 
field by no means new or wanting in honorable 
achievement. Dr. Munde has added to his already 
enviable reputation by the manner in which he 
has acquitted himself in an undertaking at once 
so delicate and difficult and for which he will 
receive, at the hands of the profession, their ac- 
knowledgment. — The Brooklyn Med. Jou?., Mar. '92. 



TAIT, LAWSON, F.B. C.S., 

Professor of Gynaecology in Queen's College, Birmingham; late President of the British Gyne- 
cological Society ; Fellow American Gynecological Society. 

Diseases of Women and Abdominal Surgery. In two octavo volumes. 
Volume I., 554 pages, 62 engravings and 3 plates. Cloth, $3. Volume II., preparing. 



The plan of the work does not indicate the regu- 
lar system of a text- book, and yet nearly every- 
thing of disease pertaining to the various organs 
receives a fair consideration. The description of 
diseased conditions is exceedingly clear, and the 
treatment, medical or surgical, is very satisfactory. 



Much of the text is abundantly illustrated with 
cases, which add value in showing the results of 
the suggested plans of treatment. We feel con- 
fident that few gynecologists of the country will 
fail to place the work in their libraries. — The 
Obstetric Gazette, March, 1890. 



SUTTON, J. BLAND, F. B. C. S. 9 

Assistant Surgeon to the Middlesex Hospital, London. 

Surgical Diseases of the Ovaries and Fallopian Tubes, including 
Tubal Pregnancy. In one crown octavo volume of 544 pages with 119 engravings 
and 5 colored plates. Cloth, $3. Just ready. 

To gynecologists the name of Mr. Sutton has that the writer Jhas to say is stated in a clear, 
long been familiar as that of a conscientious 
worker in pelvic pathology, as well as a compara- 
tive anatomist of wide reputation. The present 
volume contains the substance of valuable papers 
which have been scattered throughout jouraals 
and society reports during the past five or six 
years, and deserves the careful attention of gen- 
eral readers as well as of specialists. Everything 



practical way. The author's style is singularly 
concise— almost epigrammatic. Statements which 
in a less weighty authority might appear too dog- 
matic gather force by the positive manner in 
which they are made. We have no hesitation in 
pronouncing it the best monograph of the kind 
which has yet appeared. — Medical Record, New 
York, May 21, 1892. 



DAVENPORT, F. PL., M. D., 

Astistant in Gynaecology in the Medical Department of Harvard University, Boston. 

Diseases of Women, a Manual of Non-Surgical Gynaecology. De- 
signed especially for the Use of Students and General Practitioners. New (second) 
edition, in one handsome 12mo. volume of 314 pages, with 107 illustrations. Cloth, 
$1.75. Just ready. 



Many admirable volumes already exist on the 
surgical aspects of gynecology, but scant attention 
has been paid to the non-surgical treatment of 
women's diseases, a realm of almost equal extent 
and importance. Comparatively few practitioners 
are prepared to perform the graver gynecological 
operations, but all are compelled to deal with the 
multitudinous ailments of women, and in many 
instances non-surgical measures are preferable, 



though neglected by those whose special skill has 
enlarged the field of operative interference. The 
present volume deals with nothing which has not 
stood the actual test of experience, and being 
concisely and clearly written it conveys a great 
amount of information in a convenient space. 
The demand for two editions in less than three 
years confirms its usefulness.— The Medical Brief , 
August, 1892. 



MAY, C SABLES PL., M. D., 

Late House Surgeon to Mount Sinai Hospital, New York. 
A Manual of theDiseases of Women. Being a concise and systematic expo- 
sition of the theory and practice of gynecology. Second edition, edited by L. S. Rau, 
M. D., Attending Gynecologist at the Harlem Hospital, N. Y. In one 12mo. volume of 
360 pages, with 31 illustrations. Cloth, $1.75. 



This is a manual of gynecology in a very con- 
densed form, and the fact that a second edition 
has been called for indicates that it has met with 
a favorable reception. It is intended, the author 
tells us, to aid the student who after having care- 
fully perused larger works desires to review the 
subject, and he adds that it may be useful to the 
practitioner who wishes to refresh his memory 



rapidly but has not the time to consult larger 
works. We are much struck with the readiness 
and convenience with which one can refer to any 
subject contained in this volume. Carefully com- 
piled indexes and ample illustrations also enrich 
the work. This manual will be found to fulfil its 
purposes very satisfactorily.— The Physician and 
Surgeon, June, 1890. 



Lea Brothers & Co.'s Publications — Obstetrics, Dis. of Woni. 29 



FARVIJST, THEOFHILVS, M. J)., LL. D., 

Prof, of Obstetrics and the Diseases of Women and Children in Jefferson Med. Coll., Phila. 
The Science and Art of Obstetrics. Second edition In one handsome 8vo. 
volume of 701 pages, with 239 engravings and a colored plate. Cloth, $4.25; leather, $5.25. 



The second edition of this work is fully up to the 

Present state of advancement of the obstetric art. 
he author has succeeded exceedingly well in 
incorporating new matter without apparently in- 
creasing the size of his work or interfering with 
the smoothness and grace of its literary construc- 
tion. He is very felicitous in his descriptions of 
conditions, and proves himself in this respect a 
scholar and a master. Rarely in the range of 



obstetric literature can be found a work which is 
so comprehensive and yet compact and practical. 
In such respect it is essentially a text book of the 
first merit. The treatment of the subjects gives a 
real value to the work — the individualities of a 
practical teacher, a skilful obstetrician, a close 
thinker and a ripe scholar.— Medical Record, Jan. 
17, 1891. 



PLATFAIR, W. S., M. D., F. R. C. P., 

Professor of Obstetric Medicine in King's College, London, etc. 

A Treatise on the Science and Practice of Midwifery. Fifth Amer- 
ican, from the seventh English edition. Edited, with additions, by Robert P. Harris, 
M. D. In one handsome octavo volume of 664 pages, with 207 engravings and 5 plates. 
Cloth, $4.00 ; leather, $5.00. 

tion from the moment of conception to the time 
of complete involution has had the author's 
patient attention. The plates and illustrations, 
carefully studied, will teach the science of mid- 
wifery. The reader of this book will have before 
him the very latest and best of obstetric practice, 
and also of all the coincident troubles connected 
therewith.— Southern Practitioner, Dec. 1889. 



Truly a wonderful book ; an epitome of all ob- 
stetrical knowledge, full, clear and concise. In 
thirteen years it has reached seven editions. It 
is perhaps the most popular work of its kind ever 
presented to the profession. Beginning with the 
anatomy and physiology of the organs concerned, 
nothing is left unwritten that the practical ac- 
coucheur should know. It seems that every 
conceivable physiological or pathological condi- 



In one 12mo. volume of 450 



KING, A. F. A., M. D., 

Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian Univer 
sity, Washington, D. C., and in the University of Vermont, etc. 

A Manual of Obstetrics. New (Fifth) edition, 
pages, with 150 illustrations. Cloth, $2.50. Just ready. 

A notice of the previous edition is appended. 

Dr. King, in the preface to the first edition of 

this manual, modestly states that "its purpose is 

to furnish a good groundwork to the student at 

the beginning of his obstetric studies." Its pur 



pose is attained ; it will furnish a good ground- 
work to the student who carefully reads it; and 
further, the busy practitioner should not scorn the 
volume because written for students, as it con- 
tains much valuable obstetric knowledge, some 
of which is not found in more elaborate text- 
books. The chapters on the anatomy of the 
female generative organs, menstruation, fecunda- 



tion, the signs of pregnancy, and the diseases of 
pregnancy, are all excellent and clear; but it is in 
the description of labor, both normal and abnor- 
mal, that Dr. King is at his best. Here his style 
is so concise, and the illustrations are so good, 
that the veriest tyro could not fail to receive a clear 
conception of labor, its complications and treat- 
ment. Of the 141 illustrations it may be safely 
said that they all illustrate, and that the engraver's 
work is excellent. From every standpoint we can 
most heartily recommend the book both to practi- 
tioner and student. — The Medical News, Dec. 7, 1889. 



BARNES, ROBERT, M. !>., and FAJVCOURT, M. 2>., 

Phys. to the General Lying-in Hosp., Lond. Obstetric Phys. to St. Thomas' Hosp., Lond. 

A System of Obstetric Medicine and Surgery, Theoretical and Clin- 
ical. For the Student and the Practitioner. The Section on Embryology by Prof. Milnes 
Marshall. In one 8vo. volume of 872 pp., with 231 illustrations. Cloth, $5 ; leather, $6. 

the best obstetrical opinions of the time in a 
readily accessible and condensed form, ought to 
own a copy of the book. — Journal of the American 
Medical Association, June 12, 1886. 

The Authors have made a text-book which is in 
every way quite worthy to take a place beside the 
best treatises of the period.— New York Medical 
Journal, July 2, 1887. 



The immediate purpose of the work is to furnish 
a handbook of obstetric medicine and surgery 
for the use of the student and practitioner. It is 
not an exaggeration to say of the book that it is 
the best treatise in the English language yet 
published, and this will not be a surprise to those 
who are acquainted with the work of the elder 
Barnes. Every practitioner who desires to have 



DVNCA2T, J. MATTHEWS, M.JD., LL. !>., F. R. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

They are in every way worthy of their author ; 
indeed, we look upon them as among the most 
valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 



rule, adequately handled in the text-books ; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 
stamp of individuality that they deserve to be 
widely read.— N. Y. Medical Journal. March, 1880. 



WJLWCKEL, F. 

A Complete Treatise on the Pathology and Treatment of Childbed. 

For Students and Practitioners. Translated, with the consent of the Author, from the 
second German edition, by J. K. Chadwick, M. D. Octavo 484 pages. Cloth, $4.00. 



30 



Lea Brothers & Co.'s Publications — Obstet., l>is. Childn. 



SMITH, J. LEWIS, M. D., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. T, 

A Treatise on the Diseases of Infancy and Childhood. New (seventh) 
edition, thoroughly revised and rewritten. In one handsome octavo volume of 881 
pages, with 51 illustrations. Cloth, $4.50 ; leather, $5.50. 

We have always considered Dr. Smith's book as I is always conservative and thorough, and the 
one of the very best on the subject. It has always ' evidence of research bas long since placed its 
been practical — a field book, theoretical where " 



theory has been deduced from practical experi- 
ence. He takes his theory from the bedside and 
the pathological laboratory. The very practical 
character of this book has always appealed to us. 
It is characteristic of Dr. Smith in all his writings 
to collect whatever recommendations are found in 
medical literature, and his search has been wide. 
One seldom fails to find here a practical suggestion 
after search in other works has been in vain. In 
the seventh edition we note a variety of changes 
in accordance with the progress of the times. It 
still stands foremost as the American text-book. 
The literary style could not be excelled, its advice 



author in the front rank of medical teachers.- 
The American Journal of the Medical Sciences, Dec. 
1891. 

In the present edition we notice that many of 
the chapters have been entirely rewritten. Full 
notice is taken of all the recent advances that 
have been made. Many diseases not previously 
treated of have received special chapters. The 
work is a very practical one. Especial care has 
been taken that the directions for treatment shall 
be particular and full. In no other work are such 
cartful instructions given in the details of infant 
hygiene and the artificial feeding of infants.— 
Montreal Medical Journal, Feb. 1891. 



ZANDIS, HENRY G., A. M., M. &., 

Professor of Obstetrics and the Diseases of Women in Starling Medical College, Columbus, 0. 

The Management of Labor, and of the Lying-in Period. In one 

handsome 12mo. volume of 334 pages, with 28 illustrations. Cloth, $1.75. 

The author has designed to place in the hands I as we can see, nothing is omitted. The advice is 
of the young practitioner a book in which he can sound, and the procedures are safe and practical, 
find necessary information in an instant. As far | Centralblatt fur G-ynakologie, December 4, 1886. 



HERMAN, G. ERNEST, M. B., F. R. C. P., 

Obitetrie Physician to the London Hospital. 

First Lines in Midwifery : a Guide to Attendance on Natural Labor 
for Medical Students and Midwives. In one 12mo. volume of 198 pages with 
80 illustrations. Cloth, $1.25. Just ready. See Studenfs Series of Manuals, below. 

This work is designed to give such elementary 
knowledge as may be needed by a midwife or 
student in the care of their first cases of normal 
labor, and it presents that knowledge in a clear 
and practical wav. — The American Journal of Ob- 
stetrics, April, 1892. 

This is a little book, intended for the medical 



student and the educated midwife. The work 
is written in a plain, simple style, and is as 
much as possible devoid of technical terms. It 
will prove valuable to the beginner in midwifery 
and could be read with advantage by the majority 
of practitioners, old and young.— The Medical 
Fortnightly, April 15, 1892. 



OWEN, EDMUND, M. B., F. R. C. S., 

Surgeon to the Children's Hospital, Great Ormond St., London. 

Surgical Diseases of Children. In one 12mo. volume of 525 pages, with 4 
chromo-lithographic plates and 85 woodcuts. Cloth, $2. See Series of Clinical Manuals, 
page 31. 

One is immediately struck on reading this book [ honestly recommended to both students and 
with its agreeable style and the evidence it every- • practitioners. It is full of sound information, 
where presents of the practical familiarity of its ! pleasantly given.— Annals of Surgery, May, 1886. 
author with his subject. The book may be | 



STUDENT'S SERIES OF MANUALS. 

A Series of Fifteen Manuals, for the use of Students and Practitioners of Medicine and Surgery, 
written by eminent Teachers or Examiners, and issued in pocket-size 12mo volumes of 300-540 pages, 
richly illustrated and at a low price. The following volumes are now ready: Lrorr'fi Manual of Chem- 
istry, S2; Herman's Fvst Lines in Midwifery, $1.25; Treves' Manual of Surgery, by various writers, in 
three volumes, per set, 86; each, $2; Bell's Comparative Anatomv and' Physiology, $2; Gould'6 Surgical 
Diagnosis, $2; Robertson's Ph;/siotogical Physics, $2; Bruce' s Materia Medica and Therapeutics (4th edi- 
tion). $1.50; Power's Human Physiology (2d edition), $1.50; Clarke and Lockwood's DUsectors' Man- 
ual, $1.50 ; Ralfe's Clinical Chenvstry, $1.50; Treves' Surgical Applied Anatomy, $2; Pepper's Surgical 
Pathology, $2; and Klein's Elements of Histology (4th edition), $1.75. The" following is in press: 
Pepper's Forensic Medicine. For separate notices see index on last page. 



CONDIE'S PRACTICAL TREATISE ON THE 
DISEASES OF CHILDREN. Sixth edition, re- 
vised and augmented. In one octavo volume of 
779naees Cloth. ftR.2*; leather. *fi.2«i 

LEISHMAN'S SYSTEM OF MIDWIFERY, IN- 
CLUDING THE DISEASES OF PREGNANCY 
AND THE PUERPERAL STATE. Fourth edi- 
tion. Octavo. 

WEST ON SOME DISORDERS OF THE NERV- 
OUS SYSTEM IN CHILDHOOD. In one small 
12mo. volume of 127 pages. Cloth, $1.00. 

PARRY ON EXTRA-UTERINE PREGNANCY' 
Its Clinical History, Diagnosis, Prognosis and 
Treatment. Octavo, 272 pages. Cloth, $2.50. 

CHURCHILL ON THE PUERPERAL FEVER 
AND OTHER DISEASES PECULIAR TO WO- 
MEN. In one 8vo. vol. of 464 pages. Cloth, $2.50. 

TANNER ON PREGNANCY. Octavo, 490 pages, 
colored plates, 16 cuts. Cloth, $4.25. 



ASHWELL'S PRACTICAL TREATISE ON THE 
DISEASES PECULIAR TO WOMEN. Third 
American from the third and revised London 
edition. In one 8vo. vol., pp. 520. Cloth. $3.50. 

MEIGS ON THE NATURE, SIGNS AND TREAT- 
MENT OF CHILDBED FEVER. In one 8vr. 
volume of 34« oages. Cloth. $2.00. 

RAMSBOTHAM'S PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND 
SURGERY. In reference to the Process of 
Parturition. A new and enlarged edition, thor- 
oughly revised bv the Author. With additions 
by W. V. Keating, M. D., Professor of Obstetrics, 
etc., in the Jefferson Medical College of Phila- 
delphia. In one large and handsome imperial 
octavo volume of G40 pages, with 64 full page 
plates and 43 woodcuts in the text, containing in 
all nearly 200 beautiful figures. Strongly bound 
in leathe'r, with raised bands, $7. 



Lea Brothers & Co.'s Publications— Med. Juris., Miscel. 31 

SERIES OF CLINICAL MANUALS. 

In arranging for this Series it has been the design of the publishers to provide the profession with 
a collection of authoritative monographs on important clinical subjects in a cheap and portable form. 
The volumes contain about 550 pages and are freely illustrated by chromo-lithograpns and wood- 
cuts. The following volumes are now ready: Yeo on Foodin Health and Disease, 82; Broadbent on 
the Pulse, 81.75; Carter <fe Frost's Ophthalmic Surgery, 82 25; Hutchinson on Syphilis, 82.25; Ball on 
the Rectum and Anus, 82-25; Marsh on the Joints, $2; Owen on Surgical Diseases of Children, 82; 
Morris on Surgical Diseases of the Kidney, 82.25 ; Pick on FracturesJand Dislocations, 82 ; Butlin on 
the Tongue, 83.50; Treves on Intestinal Obstruction, 82; and Savage on Insanity and Allied Neuroses, 82. 
The following is in active preparation: Lucas on Diseases of the Urethra. For separate notices see 
index on last page. 

TAYLOB, ALFBEJD 8., M. I>., 

Lecturer on Medical Jurisprudence and Chemistry in Quy's Hospital, London. 

A Manual of Medical Jurisprudence. New American from the twelfth 
English edition. Thoroughly revised by Clark Bell, Esq., of the New York Bar. In 
one octavo volume of about 900 pages, with illustrations. Shortly. 

This work is the authority recognized not only by the medical profession but also by the 
Courts of all English-speaking countries. The present (9th) American edition, being based 
on the. llth English edition, has had the benefit of successive revisions by the foremost 
medical experts, and finally by a legal authority who has made the subject an especial study 
from the standpoint of American practice. 

By the Same Author. 
Poisons in Relation to Medical Jurisprudence and Medicine. Third 
American, from the third and revised English edition. In one large octavo volume of 788 
pages. Cloth, $5.50 ; leather, $6.50. 

BEPPEB, AUGUSTUS J., M. S., M. B. 9 F. B. C. S. 9 

Examiner in Forensic Medicine at the University of London. 
Forensic Medicine. In one pocket-size 12mo. volume. Preparing. See Students 7 
Series of Manuals, below. 

LEA 9 HENBY C, LL. JD. 

Chapters from the Religious History of Spain.— In one 12mo. volume 
of 522 pages. Cloth, $2.50. 

The width, depth and thoroughness of research 
which have earned Dr. Lea a high European place 
as the ablest historian the Inquisition has yet 



found are here applied to some side-issues of that 
great subject. We have only to say of this volume 
that it worthily complements the author's earlier 
studies in ecclesiastical history. His extensive 
and minute learning, much of it from inedited 
manuscripts in Mexico, appears on every page. — 
London Antiquary, Jan. 1>91. 

After attentively reading the work one does not 
know whether the author is a Catholic, a Protestant 



or a free-thinker. This moderation deprives the 
indictment of none of its force. The facts and 
the documents, of which the number and novelty 
attest a patient erudition, are grouped in luminous 
order and produce on the reader an effect all the 
more powerful in that it seems the less designed. 
When we add that the style is in every way excel- 
lent, that it is clear, sober and precise, we do full 
justice to a work which reflects the highest honor 
on the talents of the writer and on the method of 
the modern school of history. — Revue Critique 
d'Hist'jire et de Literature, Paris, Jan. 1891. 



By the same Author. 
Superstition and Force : Essays on The Wager of Law, The Wager of 
Battle, The Ordeal and Torture. Revised and enlarged edition. In one hand- 
some royal 12mo. volume of about 600 pages. New (fourth) edition. In press. 



By the Same Author. 
Studies in Church History. The Rise of the Temporal Power— Ben- 
eflt of Clergy— Excommunication— The Early Church and Slavery. Sec 
ond and revised edition. In one royal octavo volume of 605 pages. Cloth, $2.50. 

The author is preeminently a scholar; he takes 
up every topic allied with the leading theme and 
traces it out to the minutest detail with a wealth 



of knowledge and impartiality of treatment that 
compel admiration. The amount of information 
compressed into the book is extraordinary, and 
the profuse citation of authorities and references 
makes the work particularly valuable to the student 
who desires an exhaustive review from original 
sources. In no other single volume is the develop- 
ment of the primitive church traced with so much 
clearness and with so definite a perception of 



complex or conflicting forces. — Boston Traveller. 
It is some years since we read the first edition 
of this work by Mr. Lea, and the impression made 
by it on us at the time is confirmed by reperusal 
ol it in this enlarged and improved form ; namely, 
that it is a book of great research and accuracy, 
full of varied information on very interesting 
phases of church life and history. It discusses 
each subject with a rare fulness of dates and in- 
stances, and a curious conscientiousness of veri- 
fication and citation of authorities.— Edinburgh 
Scotsman. 



By the Same Author. 
An Historical Sketch of Sacerdotal Celibacy in the Christian 
Church. Second edition, enlarged. In one octavo volume of 685 pages. Cloth. $4.50. 
This subject has recently been treated with very I more light on the moral condition of the Middle 
great learning and with admirable impartiality by Ages, and none which is more fitted to dispel the 
an American author, Mr. Henry C. Lea, in his His- ' gross illusions concerning that period which posi- 
tory of Sacerdotal Celibacy, which is certainly one j tive writers and writers of a certain ecclesiastical 
of the most valuable works that America has pro- | school have conspired to sustain.— Lecky's History 
duced. Since the great history of Dean Milman, of European Morals, Chap. V. 
I know no work in English which has thrown I 



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Abbott's Bacteriology . , 

Ellens Anatomy .... 

American Journal of the Medical Sciences 
American Systems of Gynecology and Obstetrics 
American System of Practical Medicine . 
American System of Dentistry 
A shhurst's Surgery .... 
Ashwell on Diseases of Women 
Attfield's Chemistry . 
Ball on the Rectum and Anus 
Barlow's Practice of Medicine 
Barnes' System of Obstetric Medicine 
Bartholow on Electricity 
Basham on Renal Diseases t 
Bell's Comparative Anatomy and Physiology 
Bellamy's Surgical Anatomy 
Berry on the Eye .... 

Billings' National Medical Dictionary . 
Blandford on Insanity 
Bloxam's Chemistry .... 
Bristowe's Practice of Medicine 
Broadbent on the Pulse 
Browne on Koch's Remedy . 
Browne on the Throat, Nose and Ear 
Bruce's Materia Medica and Therapeutics 
Brunton's Materia Medica and Therapeutics 
Bryant's Practice of Surgery . 
Bumstead and Taylor on Venereal. See Taylor, 
Burnett on the Ear 
Butlin on the Tongue . 
Carpenter on the Use and Abuse of Alcohol 
Carpenter's Human Physiology 
Carter & Frost's Ophthalmic Surgery 
Chambers on Diet and Regimen . 
Chapman's Human Physiology 
Charles' Physiological and Pathological Chem. 
Churchill on Puerperal Fever 
Clarke and Lockwood's Dissectors' Manual 
Classen's Quantitative Analysis 
Cleland's Dissector .... 
Clouston on Insanity . 
Clowes' Practical Chemistry 
Coats' Pathology 
Cohen on the Throat 
Cohen's Applied Therapeutics 
Coleman's Dental Surgery . 
Condie on Diseases of Children 
Cornil on Syphilis 
Cullerier & Bumstead on Venereal 
Culver & Hayden on Venereal Diseases . 
Dalton on the Circulation 
Dalton's HumanPhysiology 
Davenport on Diseases of Women . 
Davis' Clinical Lectures 
Draper's Medical Physics 
Druitt's Modern Surgery 
Duncan on Diseases of Women 
Dungllson's Medical Dictionary 
Edes' Materia Medica and Therapeutics 
Edison Diseases of Women . 
Ellis' Demonstrations of Anatomy 
Emmet's Gynaecology 
Erichsen's System of Surgery 
Farquharson's Therapeutics and Mat. Med. 
Finlayson's Clinical Diagnosis 
Flint on Auscultation and Percussion 
Flint on Phthisis .... 

Flint on Respiratory Organs 
Flint on the Heart 

Flint's Essays ..... 
Flint's Practice of Medicine 
Folsom's Laws of U. S. on Custody of Insane 
Foster's Physiology .... 
Fothergill's Handbook of Treatment 
Fownes' Elementary Chemistry . 
Fox on Diseases of the Skin . 
Frankland and Japp's Inorganic Chemistry 
Fuller on the Lungs and Air Passages . 
Gant's Student's Surgery 
Gibbes' Practical Pathology 
Gould's Surgical Diagnosis . 
Gray's Anatomy ..... 
Gray on Nervous and Mental Diseases . 
Green's Pathology and Morbid Anatomy 
Greene's Medical Chemistry . 
Griffith's Universal Formulary 
Gross on Foreign Bodies in Air- 
Gross on Impotence and Sterility 
Gross on Urinary Organs 
Gross System of Surgery 
Habershon on the Abdomen . 

Hamilton on Fractures and Dislocations 
Hamilton on Nervous Diseases 
Hare's Practical Therapeutics 
Hare's System of Practical Therapeutics 
Hardaway on the Skin 
Hartshorne's Anatomy and Physiology . 
Hartshorne's Conspectus of the Med. Sciences 
Hartshorne's Essentials of Medicine 
Herman's First Lines in Midwifery 
Hermann's Experimental Pharmacology 
Hill on Syphilis ..... 
Hillier's Handbook of Skin Diseases 
Hirst <fe Piersol on Human Monstrosities 
Moblyn'a Medical Dictionary 
Hodge on Women 

Hoffmann and Power's Chemical Analysis 
Holden's Landmarks .... 
Holland's Medical Notes and Reflections 
Holmes' Principles and Practice of Surgery 
Holmes' System of Surgery 
Horner's Anatomy and Histology 
Hudson on Fever 
Hutchinson on Syphilis 
Hyde on the Diseases of the Skin . 
Jackson on the Skin . 
Jamieson on the Skin 
Jones (C. Handfleld) on Nervous Disorders 



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29 
9 
20,31 
16 j 
29 
16 
24 
7,30 
6 ! 
23 | 
4 
19 

13 

17,31 

17 

17 

11,30 

12 

21 

25 

23 

20,31 

7 

7 

23,31 

16 

8 
10 
30 
6,30 
10 

6 
19 

8 
18 
17 
13 
24 
30 
25 
25 
25 

7 

8 
28 
16 

7 

20 
29 

5 
11 
27 

7 
27 
21 
12 
15 
17 
13 
17 
13 
13 
13 
19 

8 
15 

9 
26 

9 
16 
20 
18 
20,30 

5 

19 
18 

9 
11 
17 
25 
25 
20 
15 
22 
19 
12 
12 



11 
25 
25 

6 

4 
27 
10 

5 
16 
22 
21 

6 
15 
25,31 
26 
26 
26 
16 



Juler's Ophthalmic Science and Practice 

King's Manual of Obstetrics . 

Klein's Histology 

Landis on Labor . ... 

La Roche on Pneumonia, Malaria, etc. . . 

La Roche on Yellow Fever .... 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Eyelid 

Lea's Chapters from Religious History of Spain 

Lea's Sacerdotal Celibacy .... 

Lea's Studies in Church History 

Lea's Superstition and Force . ... 

Lee on Syphilis . . ... 

Lehmann's Chemical Physiology . 

Leishman's Midwifery .... 

Lucas on Diseases of the Urethra . 

Ludlow's Manual of Examinations . . 

Luff's Manual of Chemistry 

Lyman's Practice of Medicine 

Lyons on Fever ...... 

Maisch's Organic Materia Medica . 

Marsh on the Joints 

May on Diseases of Women .... 

Medical News ...... 

Medical News Visiting List .... 

Medical News Physicians' Ledger . 

Meigs on Childbed Fever .... 

Miller's Practice of Surgery .... 

Miller's Principles of Surgery 

Morris on Diseases of the Kidney . 

Musser's Medical Diagnosis .... 

National Dispensatory 

National Medical Dictionary 

Nettleship on Diseases of the Eye . . . 

Norris and Oliver on the Eye 

Owen on Diseases of Children . . .30, 

Parrish's Practical Pharmacy . . . 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery . .... 

Pavy on Digestion and its Disorders . • 

Payne's General Pathology .... 

Pepper's System of Medicine 

Pepper's Forensic Medicine . . . .30 

Pepper's Surgical Pathology . . .17 

I Pick on Fractures and Dislocations . . 22 

Pirrie's System of Surgery .... 

Playfair on Nerve Prostration and Hysteria . 
i Playfair' s Midwifery ..... 
' Power's Human Physiology . . . .7 

Purdy on Bright's Disease and Allied Affections 
i Pye-Smith on the Skin .... 

I Quiz Series ...... 

Ralfe's Clinical Chemistry . . .10 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 
j Reynolds' System of Medicine 
; Richardson s Preventive Medicine 
I Roberts on Diet and Digestion 
I Roberts on Urinary Diseases 
j Roberts' Compend of Anatomy . . . 

1 Roberts' Surgery 

j Robertson's Physiological Physics . . 7 

! Ross on Nervous Diseases .... 
i Savage on Insanity, including Hysteria . . 19 

Schafer's Essentials of Histology, 
! Schreiber on Massage . ... 

Seiler on the Throat, Nose and Naso-Pharynx 
I Senn's Surgical Bacteriology 
j Series of Clinical Manuals .... 

Simon's Manual of Chemistry 

Slade on Diphtheria ..... 
! Smith (Edward) on Consumption . 

Smith (J. Lewis) on Children 

Smith's Operative Surgery 
- Stille on Cholera . ... 

Stilie & Maisch's National Dispensatory 
I Stilie's Therapeutics and Materia Medica 
j Stimson on Fractures and Dislocations 

Stimson's Operative Surgery 
. Students' Quiz Series ..... 
i Students' Series of Manuals .... 
i Sturges' Clinical Medicine .... 
I Sutton on the Ovaries and Fallopian Tubes . 
i Tait's Diseases of Women and Abdom. Surgery 

Tanner on Signs and Diseases of Pregnancy . 

Tanner's Manual of Clinical Medicine . 
i Taylor's Atlas of Venereal and Skin 

Taylor on Venereal Diseases 

Taylor on Poisons .... 

Taylor's Medical Jurisprudence 

Thomas & Munde on Diseases of Women 

Thompson on Stricture 

Thompson on Urinary Organs 

Todd on Acute Diseases 
| Treves' Manual of Surgery . 

Treves' Operative Surgery . 

Treves' Student's Handbook of Surg. Operations, 

Treves' Surgical Applied Anatomy . . * 

Treves on Intestinal Obstruction . . .21 

j Tuke on the Influence of Mind on the Body 

Vaughan <fe Novy's Ptomaines and Leucomalnes 

Visiting List, The Medical News 

Walshe on the Heart . 

Watson's Practice of Physic . 

Wells on the Eye 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Wharton's Minor Surgery and Bandaging 

Whitla's Dictionary of Treatment 

Williams on Consumption .... 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy . 

Winckel on Pathol, and Treatment of Childbed 

Wdhler's Organic Chemistry 

Woodhead's Practical Pathology . 

Year-Books of Treatment for 86. '87, '90, '91, '92. 

Yeo on Food in Health and Disease . . 16 

Young's Orthopaedic Surgery 



23 
29 

17,30 
30 
16 
15 
23 
23 
31 
31 
31 
31 
25 
7 
30 

24,30 
4 

9,30 
15 
15 
11 

22,31 
28 
1 
6 
S 
30 



24,31 



21,30 
21 
21 



